G2 Section II Report

SECTION II: DISASTER
MENTAL HEALTH AND

HIGH-VULNERABILITY
POPULATIONS
DEFINING AND UNDERSTANDING
VULNERABILITY:
In 1987, a big storm called a tornado hit Saragosa, a small town in Texas. Almost half of the town was
destroyed by the tornado. Saragosa had about 400 people, and most of them were Mexican and spoke
Spanish. But the warnings about the tornado weren't given in a way that the people there could easily
understand. Even the messages in Spanish weren't translated well. Because of this, many people didn't
know they needed to find shelter from the tornado. As a result, 30 people died, and 120 got hurt.
In 1988, a big earthquake hit Armenia, a country in Europe. It caused a lot of damage and sadly, around
25,000 people died because of it. Many of those who died were kids and teenagers who were in schools
when the earthquake happened. The schools weren't built well enough to withstand the earthquake, so it
collapsed, and that's why so many young people lost their lives.
What can we learn from the examples
mentioned before and many other cases in
disaster research?
First, Some groups in society are more likely to suffer damage and loss during disasters than others.
These include people who are poor, immigrants, non-native speakers, women, children, the elderly, and
those with disabilities. These groups often have limited access to money and social support, and they
may not have much control over their lives. They also tend to live and work in places that are more
dangerous during disasters, like areas prone to flooding or earthquakes. Because of these factors, they
face higher risks of getting sick or dying during disasters.
Second, the aforementioned demographic characteristics— socioeconomic status, race, gender, age,
disability—intersect in complex and dynamic ways that may increase or decrease the vulnerability of any
given member of a social group.
What can we learn from the examples
mentioned before and many other cases in
disaster research?
Third, In the last ten years, there has been a shift in how we think about vulnerable groups during
disasters. Instead of just listing specific groups, like children or the elderly, researchers now focus on
"vulnerable situations." This means looking at the specific circumstances and places where people live,
and how these factors make them more at risk during disasters. For example, the children who died in
the Armenian earthquake might have been safe if it hadn't been during school hours. Similarly, many
women and children died in the 2004 tsunami because they were waiting on the shore for their
husbands to return with fish. This approach also reminds us that people may become more or less
vulnerable depending on their age and stage of development, or due to injuries, pregnancy, or other
temporary health conditions.
Disasters can be influenced by various
factors:
Social Factors: Social structures and inequalities can play a significant role in determining who is most
affected by disasters. For example, marginalized communities may lack access to resources and proper
infrastructure, making them more vulnerable.
Political Factors: Government policies, regulations, and emergency response strategies can impact the
severity and aftermath of disasters. Inadequate planning, corruption, or mismanagement can
exacerbate the effects of natural hazards.
Disasters can be influenced by various
factors:
Economic Factors: Economic conditions can influence a community's ability to prepare for and recover
from disasters. Poverty, unemployment, and unequal distribution of wealth may limit resources available
for mitigation and response efforts.
Environmental Factors: Environmental factors such as climate change, deforestation, and urbanization
can increase the frequency and intensity of natural hazards, contributing to the occurrence of disasters.
MODELS FOR UNDERSTANDING
VULNERABILITY
MEDICAL MODEL
This model focuses on diseases, injuries, or health problems that affect how someone functions
normally – whether physically, mentally, or socially. It's helpful for public health plans and policies
because it focuses on treatments and actions to manage, reduce, or prevent these problems.
The medical model represents diagnosing health problems and finding the right treatments.
VULNERABILITY
FUNCTIONAL MODEL
The functional model, also known as the "social model," looks at vulnerability in a different way
compared to the medical model. Instead of focusing only on individual weaknesses or disabilities, it
looks at how the environment – including buildings, society, and politics – affects people's ability to
function. This model says it's society's job, not just the individual's, to make changes that help everyone,
especially those who need extra support with things like communication, health, independence, safety,
and transportation. In disasters, this approach aims to give everyone the same chances to get help or
take actions on their own. Throughout the different stages of a disaster – like getting preparedness,
response, recovery, and mitigation – it's important for everyone to plan ahead. But it's also crucial for
professionals and the whole response system to be inclusive, adaptable, and ready to remove obstacles,
work with everyone involved, and use resources wisely.
VULNERABILITY
Inclusive: Being inclusive means making sure that everyone is included and involved, regardless of their
background, abilities, or differences. In the context of disaster response, being inclusive means
considering the needs of all individuals and communities, including those who may face barriers due to
disabilities, language, culture, or socio-economic status. It involves actively seeking out and valuing
diverse perspectives and ensuring that everyone has equal access to resources, information, and
support.
Adaptable: Being adaptable means being able to adjust and change according to different
circumstances or needs. In disaster response, being adaptable involves being flexible and responsive to
evolving situations, challenges, and priorities. It means being open to new ideas, approaches, and
solutions, and being willing to modify plans or strategies as necessary to meet the needs of affected
individuals and communities.
VULNERABILITY
Ready to Remove Obstacles: This means being prepared and willing to identify and eliminate barriers or
challenges that may prevent individuals or communities from accessing help, resources, or
opportunities during a disaster. It involves actively addressing factors such as physical barriers,
discrimination, and limited access to information or services. It also means advocating for changes in
policies, practices, or infrastructure to create a more inclusive and equitable environment for everyone.
VULNERABILITY
To demonstrate the need to understand a wider social context, Think about two 87-year-old people. One
might be perfectly capable of taking care of themselves during a disaster once provided the appropriate
information on which to act. But the other might have health issues that make it harder for them to take
care of themselves, even if they have money to pay for help.
Now, imagine one of those 87-year-olds is deaf, and important instructions are only given through
spoken English on a loudspeaker. This makes it hard for them to understand and protect themselves.
But if they get the information in writing, sign language, or another way they can understand, they're
more likely to stay safe. Similarly, if someone doesn't speak much English, giving them information in
different languages and formats will help them take the right actions to stay safe.
UNDERSTANDING VULNERABILITY
SYSTEMATICALLY AS A BASIS FOR
INTERVENTION
FIRST-MICRO LEVEL
At the first level of the ecosystem, called the microlevel, we look at individuals, families, and households.
Here, vulnerability to disasters can be influenced by a person's unique traits, like their personality and
health, as well as by their family situation and the resources they have.
For example, if someone is socially isolated, they might miss important warnings about disasters or
struggle with mental health issues like depression. Having a strong social network can help reduce this
risk because people who care about you can provide support and help you stay safe. However, factors
like low income, old age, disability, or medical conditions can make it harder to access resources or
prepare for disasters. People with limited income might struggle to afford things like extra medications
or gasoline for evacuation.
INTERVENTION
SECOND-MESO LEVEL
At the second level, called the meso-level, organizations work together to reduce the impact of
disasters. Traditionally, this includes emergency management agencies and healthcare providers. For
example, during pandemics, efforts are made to set up places where people can easily get medications.
But other partners can also help at this level. Healthcare organizations, for instance, can share
information at different places like clinics, outreach centers, and home health agencies. They can team
up with advocacy groups and community organizations to reach even more people. These efforts can
make a difference in people's daily lives by reaching them. Additionally, organizations at this level can
gather resources to help people who have trouble accessing healthcare due to economic challenges or
medical needs.
INTERVENTION
THIRD-EXO LEVEL
At the exo-level, we're talking about policies – rules and plans made by governments. Before Hurricane
Katrina, there wasn't much focus on making sure policies helped people with disabilities or medical
needs during disasters in the United States. But things changed after Katrina. Now, there are policies in
place to make sure everyone's needs are considered, like having housing plans that include people with
disabilities. For example, FEMA (the Federal Emergency Management Agency) has a special office
focused on including people with disabilities in disaster planning. They have experts and interpreters to
help make sure everyone is included. The Federal Highway Administration also made a guide on how to
evacuate people who are medically fragile. In 2016, several government departments put out guidelines
to make sure state and local governments follow laws that protect the rights of all people during
emergencies. These examples show how policies at the exo-level are improving to help people who are
at high risk during disasters.
INTERVENTION
FOURTH-MACRO LEVEL
At the macro-level, we're looking at big-picture factors like history, culture, and geography that affect how
vulnerable people are during disasters. For example, racism and laws that forced certain groups of people
to live in specific areas have put them at risk, like living in flood-prone areas or places affected by climate
change. Two examples are Princeville, North Carolina, and the Lower Ninth Ward of New Orleans, which
are both mostly African American communities. These areas suffered a lot of damage from hurricanes
because they were historically marginalized. In Princeville, segregation meant that older African American
residents, mostly women, were hit hard by hurricanes in 1999 and 2016. In the Lower Ninth Ward, where
most residents are older and African American, only a quarter of the population had returned five years
after Hurricane Katrina because of political neglect and the high damage caused by the storm. These
examples show how historical and cultural factors at the macro-level can lead to higher risks and less
recovery for certain communities during disasters. (Phillips, Stukes, & Jenkins, 2011).
USING AN EQUITY AND EMPOWERMENT
LENS
Equity means providing everyone with what they need to succeed, which is different from treating
everyone the same (equality). To achieve fairness in emergencies and disasters, we need to understand
and address the unique needs of high-risk groups.
The Equity and Empowerment Lens asks us to consider four domains: People, Place, Process, and Power.
We ask questions in each domain to understand who is affected, what the benefits and burdens are, and
how to minimize harm.
In the People domain, we think about individuals, groups, or communities affected by decisions. We
consider who benefits and who might be harmed.
The Place domain is about physical space and the social connections and meaning it holds. We look at
the pros and cons of different places and how they impact communities.
LENS
The Process domain is about the way decisions are made, like the rules and plans in place. We need to
ask questions about how to involve everyone in a fair and respectful way. How we make decisions is just
as important as what we decide and why.
Lastly, the Power domain focuses on who makes the decisions and who is affected by them. Like with the
process, we need to think about how to include everyone in decision-making and build respectful
relationships. It's important to consider how decisions affect power dynamics and make sure everyone's
voices are heard, especially those who are often left out.
LENS
THE LIFE CYCLE OF DISASTERS
Any disaster, whether it's natural or man-made, goes through different stages, kind of like a life cycle.
These stages are:
Preparedness: Getting ready to respond before the disaster happens.
Response: Taking quick actions to protect people, property, and the environment as soon as the disaster
occurs.
Recovery: Fixing things and dealing with the aftermath to get back to how things were before, or even
better.
Mitigation: Doing things to reduce the impact of future disasters.

PREPAREDNESS
Preparedness means getting ready for disasters before they happen. This involves planning and training
for individuals, families, organizations, businesses, and communities. It includes understanding the
specific dangers, risks, and impacts of possible disasters, and figuring out what to do if one occurs.
Hospitals and healthcare systems, for example, have programs like the Hospital Preparedness Program
(HPP) to help them get ready for emergencies. These programs help hospitals improve their ability to
handle large numbers of patients during emergencies. Nursing homes and long-term care facilities also
have guidelines to follow to make sure they're prepared. In 2016, the Centers for Medicare and Medicaid
Services (CMS) issued a rule requiring healthcare providers to have emergency plans in place for natural
and man-made disasters. Nurses will play a key role in developing these plans and participating in training
and testing to make sure everyone is ready.
PERSONAL PREPAREDNESS
Nurses can help people and families get ready for emergencies. They can talk to patients before they
leave the hospital, asking questions like, “What equipment and supplies do you need to have with you
ready to take in an emergency? “ Some home healthcare agencies also teach patients about preparing for
disasters during home visits. Nurses can also create materials and training to make sure information is
easy to understand and available in different formats. Using a lens focused on fairness and
empowerment helps nurses consider all aspects of a person's life when talking about preparedness. It's
important to remind people to include their pets and service animals in their plans too. Healthcare
agencies should also tell clients how they'll operate during emergencies so people can plan accordingly.
Nurses and healthcare workers should also be prepared themselves, with plans for getting to work and
taking care of loved ones.
ORGANIZATIONAL PLANNING AND
PREPAREDNESS
Different organizations that help vulnerable people, like government agencies, not-for-profit organizations,
schools, and businesses, also need plans to keep running after a disaster. Healthcare providers should
make plans to keep their services going too. These plans should involve people from different parts of the
organization, like managers, staff, patients, and partners in the community. By bringing together a diverse
group of people, we can come up with better ideas and solutions to make sure everyone stays safe and
supported during and after a disaster.
PREPAREDNESS
Emergency Plans: The emergency plans of an agency explain the role and actions of the organization in
responding to the specific needs of that agency in a disaster, as well as the role that the agency will play
in a community-wide response to a disaster. The following are some examples of emergency-related
planning issues that pose challenges to planners and questions that should be answered in the planning
process.
Notification: How will patients/clients/students be notified during an emergency? Will the agency be
making home visits/phone calls to check in on people? What kinds of alternate communication methods
will be utilized to ensure that patients/families/caregivers can receive and understand information and
follow instructions?
PREPAREDNESS
Evacuation: How will patients/clients/students evacuate who have mobility disabilities and are unable to
use the stairs? Will specialized evacuation equipment be purchased? What kind of vehicles will be needed
to evacuate people and relocate to another location? What kind of facility will be safe to evacuate
patients/ clients/students based on their medical and functional needs? Will staff accompany people to
an evacuation site? Will a service animal be accompanying the individual as well?
PREPAREDNESS
Continuity of Operations Plans (COOPs): These plans go hand in hand with emergency plans and focus on
how an organization will keep doing important tasks during an emergency. For agencies that provide
crucial medical services like dialysis or cancer treatments, keeping services going without interruption is
really important for patients.
Essential Functions: What functions of the agency are critical? What functions provide critical
care/assistance to individuals/families? How will these be staffed and carried out during different types
of emergencies?
Staffing: How will staff be notified of the situation? What kind of responsibility do they have to the agency
versus their own family? Where are they located and how can they communicate with the agency, where
should they report, and so forth.
TRAINING AND EXERCISES
Training and exercises are important for making sure emergency plans work well. One initiative called the
National Nurse Emergency Preparedness Initiative (NNEPI) focuses on training nurses for emergencies.
They have a web-based course called "Nurses on the Front Line" to teach nurses how to handle
emergencies in different settings.
Nurses can play a big role in training. They can:
● Include training on working with diverse and at-risk groups.

● Learn about emergency management structure and how it helps vulnerable people.
● Work with organizations that help vulnerable people to understand their needs better.
● Get experts to help make training materials and include issues faced by vulnerable groups.
● Teach staff their roles during emergencies and how to help vulnerable people.
● Make sure training is accessible for everyone, like providing materials in different formats and
offering childcare.
TRAINING AND EXERCISES
Exercises
● Involve staff from varying levels of practice, settings, and expertise within the agency to participate
in planning exercises as they bring valuable perspectives to the process.
● When planning exercises, include challenges that test how well the agency can help vulnerable
people. Make sure to set goals for this and have ways to measure how well it's done.
● Use people from diverse backgrounds to act out scenarios during exercises. This makes the
exercise more realistic.
RESPONSE
The response phase of the disaster life cycle encompasses the period during and immediately after a
disaster occurs. FEMA defines response as the immediate actions to save lives, protect property and the
environment, and meet basic human needs. Response also includes the execution of emergency plans
and actions to support short-term recovery (FEMA, 2008).
COLLABORATION
Response to a disaster also requires collaboration among governmental and public partners that make up
the response network. In terms of addressing high-risk, high-vulnerability populations, those working in
the health sector will necessarily coordinate response within their sector.
Because of their exposure through the healthcare sector, nurses have a distinct understanding of the
diversity of the community and the impact that disasters can have during the response phase. Nurses can
improve emergency plans by sharing their experiences and advocating for their patients on committees
that plan for emergencies. These committees, often organized by local emergency management agencies
or healthcare groups, benefit from the diverse perspectives nurses bring. Nurses can reach out to their
local emergency management agencies to get involved and provide valuable insights for planning for
communities at higher risk during disasters.
RESPONSE ACTIVITIES
During the response phase of a disaster, nurses can support and advocate for high-risk, high-vulnerability
populations by improving communication and notification methods. There's no single way to do this, as it
depends on the situation and the people involved. Here are some suggestions:
● Use sign language interpreters, either in person or remotely.

● Provide language interpreters, either in person or through technology.
● Customize internal communication systems for patients and staff.
● Use different communication tools, like pointing boards or high-tech devices.
● Make sure alarm systems can be heard and seen by everyone.
● Use various technologies like TV, phones, email, and social media to reach different age groups.
● Match staff members' communication skills to the needs of the population.
RESPONSE ACTIVITIES
Temporary Healthcare or Shelter Sites: During the response phase of a disaster, when alternate care and
shelter sites are set up, it's important to make sure they meet the needs of everyone. Nurses can help by
advocating for these needs and identifying them. Here are some ways to ensure diverse needs are
accounted for:
● Make sure sites meet accessibility standards, using a checklist from the U.S. Department of
Justice.
● Identify individual needs during intake or triage and have a plan to meet those needs.
● Provide separate spaces for specific needs like quiet rooms, supervised children's areas, or private
counseling rooms.
● Arrange for refrigeration of medications or special food.
● Ensure power supplies for medical equipment like oxygen machines or wheelchairs, possibly using
alternate locations like fire stations.
RESPONSE ACTIVITIES
● Keep durable medical equipment like wheelchairs and walkers readily available.
● Identify organizations and suppliers that can provide additional equipment and supplies.
● Create agreements with skilled staff who can offer support and expertise at the site.
● Use different methods to communicate effectively with people at the site.
Decontamination:
● Undergoing decontamination operations can challenge high-risk, high-vulnerability populations.
There are specific steps that can be taken to mitigate risk, injury, and/or trauma that can all cause
deteriorating conditions and limit independence. The following are examples of ways to mitigate the
impact:
● Find ways to clean or replace medical equipment and supplies and reconnect them with their
owners.
● Identify and address individual needs systematically, involving caregivers and families.
● Practice decontaminating service animals or pets and reuniting them with their owners.
● Use different methods to communicate effectively with people at the site.
● Respect privacy and safety concerns of individuals.
● Provide separate decontamination options for different genders.
● Develop plans to manage medication needs.
● Support caregivers in helping their children through the process.
RECOVERY
Recovery after a disaster aims to get things back to how they were before, but often changes things
permanently, creating a "new normal." Short-term recovery involves fixing immediate problems like
restoring power and providing temporary housing. Long-term recovery means rebuilding infrastructure
and communities, restoring routines, and improving mental health. Some communities try to make
improvements after disasters. Planning for recovery before a disaster can make things easier afterward.
High-risk, vulnerable groups often face complex recovery issues and may need extra help. After a
disaster, their needs may continue for a long time, requiring special attention.
● Health services like check-ups, treatments, therapy, and counseling.

● Housing that's safe and fits their needs.
● Special resources like medical devices (like ramps or lifts) that aren't always provided.
● Childcare or adult daycare so caregivers can focus on recovery.
MITIGATION
Mitigation is about taking actions to make communities safer and reduce the impact of disasters. It aims
to prevent or lessen the damage caused by natural or human-made disasters, ultimately saving lives and
protecting property. By addressing the cycle of disaster damage, reconstruction, and repeated damage,
mitigation helps create safer and more resilient communities.
Mitigation involves actions to make communities safer and more resilient against disasters. It can be
structural, like changing buildings, or nonstructural, like improving education and awareness. Both types
aim to reduce risk and enhance long-term community well-being. Examples include building stronger
structures and educating people about disaster preparedness.
MITIGATION
Structural mitigation examples:
● Strengthen current buildings and construct new ones—hospitals, clinics, residential care facilities—
to withstand likely hazards such as tornadoes, hurricanes, or flooding. This may prevent damage
resulting in injury/death and/ or the need for evacuation.
● Identify facilities that may support response and recovery operations (e.g., a shelter or recovery
assistance site) and identify ways to harden and stock these sites.
MITIGATION
Nonstructural mitigation examples:
Protect critical supplies and keep them in safe areas. For example, in areas likely to experience
earthquakes, tie and secure cabinets, containers, and shelves. Plan for quick restocking from reliable
suppliers and store hard-to-replace items off-site if possible.
● Install alarm systems to immediately warn of dangers like fire, smoke, or gas leaks.
● Backup vital documents and medical records off-site to safeguard against loss in disasters like
floods.
● Establish backup communication systems internally and externally to ensure connectivity during
emergencies.
● Purchase and maintain appropriate insurance that is specific to protecting against hazards. FEMA
offers flood insurance for flood damage to properties, residences, and buildings through the
National Flood Insurance Program (NFIP).
● Educate staff and patients/clients on mitigation measures that are important for them to take.
GUIDING PRINCIPLES
● Professional Continuing Education: Continually learn about ways to improve the integration of high-
risk, high-vulnerability populations in emergency management programs during all phases of
disaster. Provide training for staff and clients on emergency preparedness as well as opportunities
for cross-training with partner organizations and agencies on emergency plans and procedures.
● Involvement: Build sustainable relationships with individuals and organizations that represent high-
risk, high-vulnerability populations. Collaborate to identify and validate needs, solutions, and
resources to lessen the impact of disasters on individuals, families, and communities.
● Assessment: Establish informal and formal assessments to measure the integration of high-risk,
high-vulnerability populations in emergency programs.
● Flexibility: Programs and plans must be flexible to allow for improvement and change toward a
greater outcome in serving high-risk, high-vulnerability populations in all phases of disaster.
GUIDING PRINCIPLES
● Building Capacity: Create plans, build resources, train staff and clients, and exercise plans to build
capacity of individuals, families, and communities. For those visiting nurses or others providing in-
home service delivery, this can be an extremely beneficial way to ensure direct awareness and
planning takes place to mitigate further risks for certain persons.
● Coordination: Coordinate resources, information, and plans across organizations, governmental
agencies, and health systems to maximize resources and more effectively meet the needs of
individuals, staff, organizations, and communities in all phases of disasters.
● Collaboration: Apply the nursing perspective and skills knowledge in a related position not
necessarily as a practicing nurse. This could be by establishing a rotation into a local emergency
management office as a planner.
● Anticipation: Predict future challenges for those affected by disasters, like housing or community
support loss, and address them.
● Agents of Change: Nurses can advocate for comprehensive care for disaster survivors because
they have close connections to communities and understand their needs.
SUMMARY
The term “high-risk, high-vulnerability populations” refers to people with a higher probability of being
exposed to disaster and who also face challenges in anticipating, coping with, resisting, or recovering
from disaster. Vulnerability is a complex phenomenon that is influenced by many social, economic,
cultural, and other characteristics. Both the traditional medical model and more recent functional model
offer approaches for understanding and addressing vulnerability in a disaster. In addition, understanding
vulnerability systematically using an ecosystem framework allows for more precise identification of
points of intervention at the micro-, meso-, exo-, and macro-levels. The disaster life cycle is another useful
concept for exploring vulnerability and structuring activities related to the routine disaster phases of
mitigation, preparedness, response, and recovery. Healthcare organizations and nursing professionals are
key actors in a whole community approach to reducing vulnerability to disaster, particularly for high-risk
populations.
08.
HUMAN SERVICES IN DISASTERS AND
PUBLIC HEALTH EMERGENCIES :
SOCIAL DISRUPTION, INDIVIDUAL
EMPOWERMENT, AND COMMUNITY
RESILIENCE
Juliana Sadovich and Jonathan D. White
● DESCRIBES THE RELATIONSHIP OF
NURSING AND HUMAN SERVICES IN
DISASTERS.
● PROVIDES AN OVERVIEW OF THE

SOCIETAL IMPACT OF DISASTERS AND
FRAMES THE ROLE OF HUMAN SERVICES
CHAPTER
IN EMERGENCY PREPAREDNESS,
RESPONSE AND RECOVERY OVERVIEW
● PROVIDES AN OVERVIEW OF DISASTER
CASE MANAGEMENT, INCLUDING THE
ROLE OF FEDERAL GOVERNMENT, CASE
MANAGEMENT MODEL, AND THE ROLE OF
NURSING WITHIN THE MODEL.
Human Services “Under
Clear Skies”
“Human services” have been “broadly defined approaching
the objective of meeting human needs through an
interdisciplinary knowledge base, focusing on prevention as
well as remediation of problems, and maintaining a
commitment to improving the overall quality of life of service
populations” (National Organization for Human Services,
2009).
Abraham Maslow Theory
which provides direct cash assistance; or means-
tested programs targeted to a specific need,
such as Supplemental Nutrition Assistance
Program (SNAP, better known as Food Stamps);
the Women, Infants and Children (WIC) program,
and community-run food banks, which help meet
the need for food; the Low Income Home Energy
Assistance Program (LIHEAP), Section-8
subsidized housing, and community homeless
shelters, which help meet sheltering (including
heating and cooling) needs; and Medicaid, which
helps meet the need for healthcare services
(Administration for Children and Families [ACF],
2011; Centers for Medicare and Medicaid
Services, 2011; Food and Nutrition Service,
2011).
Services program for human needs
Child Care System
Child Welfare
System
Aging Services
HUMAN SECURITY
● is a fundamental concept for the analysis of human services in
disasters.
● , the primary human service system is not local or national, but is the
international humanitarian aid system.
● is defined as safety from chronic threats, such as discrimination,
unemployment, or environmental degradation, and protection from
sudden crises, including economic collapse, environmental disasters,
acts of violence, or epidemics.
● Human insecurity can result from human actions, natural events, or
an interaction of human decisions and natural processes (United
Nations, 2003)
HUMAN SECURITY
For example, lessons learned from the December 2004 Asian
tsunamis identified that early social, psychological, and
community interventions resulted in better individual, family, and
community outcomes.
It was found that psychological support more often was effective

when based on local culture, local idioms of distress, and locally
acceptable ways of coping and dealing with grief (Chandra,
Pandev, Ofrin, Salunke, & Bhugra, 2006)
HUMAN SECURITY
Understanding the early traumatic stress reaction as a normative survival

response encourages an approach to identifying those who need
immediate professional intervention, particularly in contexts where
resources and skills are scarce (Silove & Steel, 2006).
Starting point for psychosocial recovery is to ensure the general

emergency management plan.
What is Social
Well-Being?
Social Well-Being
The idea that disasters create stress within individuals, families, and
communities is not new.
Hill and Hansen, in Man and Society in Disaster, stated “disasters

create the possibility of changed individuals in changed families
within a changed community”
4 stages of crisis
1. Approaching danger.
2. Anxiety heightens.
3. Reorganization. Occurs at some point during or after impact.
In this stage, individuals aspire to work out solutions and to
escape the crisis.
4. Change. occurs when the main threat has passed. It is at this
stage that communities are able to focus on rebuilding (Hill &
Hansen, 1962).
Human Development
Erikson conceptualized human development as a process of solving
developmental tasks.
The goals for attaining and maintaining autonomy and

independence relate to socioeconomic status and social
integration. As a result, life experiences or disadvantages in
socioeconomic status can result in reducing health and social well-
being (Davis et al., 2010).
Concept of Well-Being
Refers to optimal psychological functioning and
experience.
Two general approaches:

1. Hedonic approach- happiness in relationship to attain
pleasure and avoiding pain.
2. Eudemonic- meaning and self-actualization, and it defines
well-being as the degree to which a person is fully functioning.
(Pinquart & Sorensen, 2000).
EMPOWERMENT
Is a concept central to the domain of human services, particularly human services in
disasters.
In the case of disaster human services, the empowerment takes place at

the
● Micro-level (individual/family)
● Mezzo-level (community).
● Systems for human services in disasters are designed to promote
stabilization and viability at the community level as well as self-
sufficiency and human security at the individual and family levels.
Access to resources to meet immediate
needs and tools to restore the level of
independence and autonomy are
necessary to participate in long-term
recovery.Disaster human services are
not something done to take care of
clients, but rather they are means
made accessible to clients to take care
of themselves.
Norris and Steven (2007) found the
community resilience emerges from 4
primary sets of adaptive capacities
● Economic Development
● Information
● Communication
● Social capital
● Community competence
They defined social capital as the aggregate of resources linked to social networks.
Community competence was identified as collective action with problem-solving
and decision-making skills that arise from collective efficacy and empowerment.
HUMAN SERVICES IN DISASTER RESPONSE
AND RECOVERY
Two distinct processes define the ways of natural, technological, or intentional
disasters transform the landscape of human services needs in impacted
populations.
1. Disasters can disrupt the infrastructure by which communities meet community

members’ human needs, those disruptions in systems upon which individuals
depend can put human service systems’ clients at significant risk until the human
service infrastructure can be reconstituted.
2. Disaster impacts create new human service needs that did not exist before the
disaster event.
These manifestations of the social disruption wrought by disaster impacts give rise
to many new human service needs by depriving survivors of access to their ordinary
means to meet their own needs at all levels of Maslow’s hierarchy.
THEORIES SUPPORTING THE ROLE OF
NURSES IN HUMAN SERVICES
The writings of Florence Nightingale are relevant in the discussion of nursing in
disasters. In her book, Notes on Nursing: What It Is and What It Is Not, Nightingale
stated, “All the results of good nursing may be spoiled or utterly negative by on
defect, petty management, or in other words, by not knowing how to manage that
what you do when you are there, shall be done when you are not there” (Nightingale,
1898/2010, p. 35). This statement is consistent with the focus of empowerment in
community development. Certainly, her stated position related to harm,
“Apprehension, uncertainty, waiting, expectation, fear of surprise, do a patient more
harm than any exertion” provides a linkage between lack of understanding and
harm (Nightingale, 1898/2010, p. 35). Nightingale’s writings demonstrate her view
that nursing has a role in social well-being and empowerment.
ROLE OF NURSES IN HUMAN SERVICES
The role of nursing in human services during disasters consists of three elements.
● First, Understanding the potential human service issues for people within the disaster
impact area is the first element.
● The second element is screening for human service needs as the individuals transition
between pre- and postdisaster realities. Nurses working in disasters irrespective of
the location must screen individuals during care contacts for any human service
issues. Problem identification should be the goal of screening, with the solutions for
identified problems being the responsibility of the referral agency.
● Third, ellement is referral to the appropriate organization. In disasters, the social service
agencies are often overwhelmed, either due to a sharp and rapid increase in the
numbers of individuals requiring services and/or due to the impacts of the disaster to
the physical infrastructure and to the employees of the agency.
Case Management in Disasters
Case management seeks to understand complex needs and align
services to optimize outcomes. Case management began with the
development of social casework in the late 1800s. In the 20th
century, case management flourished as public health, nursing,
and social work disciplines emerged. Perhaps the most important
outcome of the use of case management is the decreasing
fragmentation and duplication of care while enhancing quality and
cost-effective outcomes (Huber, 2002)
The U.S. Congress authorized federal efforts to provide disaster case management (DCM)
as part of the Post-Katrina Emergency Management Reform Act (PKEMRA) in 2006.
While DCM was new to the federal government as a mechanism to address the human
service impact of disasters, this concept has been employed within the volunteer
organization community for a number of years. The Disaster Case Management Program
(DCMP) is a federal, FEMA-funded program that provides supplemental funding to states,
territories, and tribes in presidentially declared disasters with individual assistance
authorized.
As a modality of assistance to disaster survivors, DCM addresses three interconnected

challenges to recovery: infrastructural, organizational, and behavioral consequences of
disaster. These three sets of consequences combine to create heightened challenges for
disaster survivors to identify and access resources for recovery.
Nurses can provide that vital link to putting people in touch with the DCM
system, or whatever other mechanisms exist in the community to link
individuals and families impacted by disasters with human service
programs, resources, and services that can assist them in meeting their
needs.
Disasters are events that adversely impact individuals, families, and
communities. Nurses, in any care setting, have a unique opportunity to
identify human service needs and provide appropriate referrals to
human service organizations. This role in promoting social well-being
has been a part of the nurse’s role throughout history. The key to
success for the nurse to implement this role in disasters is to
understand the relationship of social well-being to health, screen
patients for human service needs, and know where to appropriately
refer patients and families to receive the necessary human services.
09.
UNDERSTANDING THE
PSYCHOLOGICAL IMPACT
OF DISASTER
BIOTERRORISM AND TOXIC EXPOSURES
Bioterrorism, intended to harm civilians, has a higher psychiatric impact
than natural disasters. (Ursano et al., 2004) emphasize uncertainty, fear,
and loss of confidence, with psychological reactions including horror,
anger, panic, and paranoia. The 2001 anthrax scare was more
psychological, highlighting the effectiveness of biological weapons in
inducing fear and confusion. Psychological responses also include
magical thinking, fear of contagion, anger at terrorists or government,
scapegoating, and loss of faith in institutions (Holloway et al., 2002).
● Foa et al. (2005) emphasize that media sensationalism and poor communication of
recommendations by officials can worsen reactions
● Recommended interventions to minimize psychological and social consequences of
suspected or actual biological exposures:
1.Provide information on the believed likelihood of such an attack and of possible
impact
2. Communicate what the individual risk is
3. Clarify that negative health behaviors, which may increase during time of stress (i.e.,
smoking, unhealthy eating, excessive drinking), constitute a greater health hazard than the
hazards likely to stem from bioterrorism
4. Emphasize that the only necessary action against terrorism on the individual level is
increased vigilance of suspicious actions, which should be reported to authorities
5. Clearly communicate the meaning of different levels of warning systems when
such warnings are issued
6. When issuing a warning, specify the type of threat, the type of place threatened, and
indicate specific actions to be taken
7. Make the public aware of steps being taken to prevent bioterrorism without
inundating people with unnecessary information
8. Provide the public with follow-up information after periods of heightened alert
COMMUNITY IMPACT AND RESOURCE ASSESSMENT
In 2004, the U.S. Department of Health and
Human Services introduced a population
exposure model designed to help planners
estimate the psychological impact of mass
violence and terrorism. The model operates on
the principle that individuals who experience the
greatest personal, physical, and psychological
exposure to trauma and the disaster scene are
likely to be the most severely affected. By
understanding these dynamics, planners can
better allocate resources to address the mental
health needs of those most impacted by such
events.
COMMUNITY IMPACT AND RESOURCE ASSESSMENT
Questions that should be addressed during predisaster planning include:
1. What are the types of disasters that are most likely to occur in my community?
2. Is there a county and state mental health disaster plan?
3. What kind of expertise is needed?
4. Who are the qualified mental health professionals in the community who can
be called upon in the event of a local disaster?
5. What resources can the local American Red Cross chapter provide to
responders and/or victims?
6. Is there a team of mental health workers specifically trained in critical incident
stress management available to debrief rescuers and hospital personnel?
NORMAL REACTIONS TO ABNORMAL EVENTS
Stress and grief reactions can vary among family members due to factors like
age, gender, ethnicity, religion, personality traits, coping skills, and past experiences
with loss. Secondary exposure to disasters can also cause stress symptoms. It's
important for survivors to know their experiences are normal due to the immense
stress they've experienced.
RESILIENCY IN THE FACE OF DISASTER

Reactions to stress and grief vary among individuals and can be influenced by
factors like age, gender, ethnicity, religion, personality, coping skills, and previous
loss experiences. Stress symptoms may occur even with secondary exposure to
traumatic events through media or retelling. It is crucial to reassure survivors that
their reactions are normal given the significant stress they have endured.
SPECIAL NEEDS POPULATION
Vulnerable Populations (Sim and Cui, 2015):
● Women Differential Vulnerability: (Donner & Rodriguez,

● Older people 2011):
● Children and young people
● People with disabilities Acknowledges varying levels of risk and vulnerability among
● People marginalized by ethnicity different populations.
Formal Vulnerability (Donner & Rodriguez, Most Vulnerable Groups (Elangovan and Kasi, 2014):
2011):
● Children
Characteristics influencing capacity to anticipate, cope ● Women
with, resist, and recover from natural hazards. ● Older population
● Disabled persons
CHILDREN AND YOUTH
Factors like poverty, mental health challenges, and exposure to

traumatic events can significantly impact children's mental well-being.
Female children, those with terrorist connections, and those exposed to
media may experience more severe reactions. War-affected children face
multiple stressors, and their response to disaster is influenced by
individual, family, and environmental factors. Adolescents may benefit
from perceived social support, and children with trauma histories or
unstable family lives are particularly vulnerable. Maintaining routines and
providing stability through interventions are crucial for helping children
cope and mitigate trauma's impact.
OLDER ADULTS
Older adults are at a higher risk of disasters due to factors like age,
disability, and lack of social support. Financial difficulties, pre existing
medical conditions, emotional stress, and care disruptions increase
vulnerability. older women face higher risk of PTSD and victimization.
Relocation stress exacerbates chronic health issues and disorientation.
Psychiatric nurses provide crucial support and follow-up.
THE SERIOUSLY MENTALLY ILL
Disasters can pose a significant psychological risk to individuals with

psychiatric disturbances, particularly those with pre-existing mental
disorders like bipolar and depressive disorders. These individuals are
vulnerable to severe stress due to lack of social support and marginal
stability. Community resources like assertive community treatment teams
can help prevent psychiatric hospitalizations and prevent neglect and
abuse during emergencies.
CULTURE AND ETHNIC SUBGROUPS
In disaster response and mental health interventions, it's crucial to

respect cultural and ethnic needs of survivors and bereaved individuals.
Mental health outreach teams should have bilingual staff and trained
translators, with professional language support preferred. Pre-disaster
planning should identify ethnic groups and ensure culturally appropriate
materials. Culturally sensitive emergency care involves understanding
dominant cultures' services, personal identities, and unique cultural values.
Large-scale disasters, like transportation incidents, require addressing
cultural needs. Lack of cultural competence among responders and
separation of survivors from familiar environments can complicate the
process.
DISASTER RELIEF PERSONNEL
1. PTSD frequency among firefighters and first responders: 10% to
20%
2. Higher risk for those lacking disaster training
3. Stress-induced symptoms in disaster work may lead to:
● Absenteeism
● Burnout
● Difficulties in personal and professional life
4. Medical personnel at local hospitals may experience intense
emotions, especially when:
● Providing services to families of the injured
● Working emergency duty after regular shifts
COMMUNITY REACTIONS AND RESPONSES
In the aftermath of a disaster, it's crucial to recognize that everyone exposed to it is affected:
1. Everyone who sees or experiences a disaster is affected by it in some way.
2. It is normal to feel anxious about your own safety and that of your family and close
friends.
3. Profound sadness, grief, and anger are normal reactions to an abnormal event.
4. Acknowledging your feelings helps you recover.
5. Focusing on your strengths and abilities helps you heal.
6. Accepting help from community programs and resources is healthy.
7. Everyone has different needs and different ways of coping.
8. It is common to want to strike back at people who have caused great pain.
MOURNING, MILESTONES, AND ANNIVERSARIES
Mourning after a disaster is facilitated by rituals like funerals

and community-wide ceremonies, online platforms for
anniversaries, and age-appropriate memorials in schools. Grief
counselors help individuals express emotions, detach from the
deceased, and reinvest in life. Worden's phases of mourning include
accepting reality, adjusting to absence, and reinvesting in new
relationships.
● Schools' crucial role in supporting children after a disaster:
● Teachers and principals well-positioned for outreach
● Establishing a warm relationship between mental health professionals and schools is
vital
● Professional contributions to schools:
● Providing information
● Allowing expression of feelings
● Screening for difficulties
● Importance of avoiding over- or under exposure to the disaster
● Resources from the National Child Trauma Stress Network:
● Child Trauma Tool Kit for Educators
● Collaborative screening by a committee, including a disaster mental health professional
● Identification of suitable resources for schools
● Large-group preventive techniques involve:
● Preconsultation
● In-class consultation with various activities
● Postconsultation ensuring follow-up and referrals as needed
● Aim of interventions:
● Address the psychological impact of disasters on children promptly and effectively
10.
MANAGEMENT OF
PSYCHOSOCIAL EFFECTS OF
DISASTERS
THE MENTAL HEALTH RESPONSE TEAM
A mental health coordinator is a crucial figure in disaster response

teams, managing mental health efforts, activating resources, and deploying
teams to various locations. Key responders include mobile crisis teams, case
managers, and preapproved volunteers, including Disaster Mental Health
teams. Psychiatric nurses and psychiatrists are vital medical team members,
alerting to organic mental disorders. Paraprofessionals and volunteers, familiar
with the affected community, maintain links and provide referrals. After
demobilization, the coordinator reviews the response, ensuring mental health
professionals are prepared for disasters, culturally competent, and provide
necessary support.
RECRUITMENT, SCREENING, AND TRAINING
Not everyone, however, is suited for disaster work. Individuals struggling with
uncertainty and chaos in disaster work should consider counseling referrals in
hospitals or clinics instead of immediate response teams. Matching skills with
response phases can avoid pitfalls, and easing guilt for helping professionals
can reduce stress. Mental health professionals during disasters must be
familiar with assessment and intervention strategies, psychologically and
physically prepared, aware of their emotional reactions, and have access to
support. They should be culturally competent, familiar with local referral
resources, and provide consultation to volunteers and paraprofessionals when
needed.
PSYCHOLOGICAL FIRST AID
After a disaster, Psychological First Aid (PFA) is implemented to reduce

psychological harm and prevent pathological consequences. PFA helps
survivors cope, identifies those needing follow-up, and educates communities
about normal reactions to extreme stress. Immediate steps include preventing
re-traumatization, limiting interactions, and avoiding forced recounting of
experiences. Efforts also involve limiting exposure to disaster sites and
avoiding pathologizing distress. Identifying individuals with acute distress is
crucial for medical intervention.
CRISIS INTERVENTION
The Substance Abuse and Mental Health Services Administration

(SAMHSA) recommends crisis intervention services as a first line of emergency
management for those affected by large-scale community disasters. These
interventions aim to help survivors decrease fear responses and access
immediate care and support, allowing them to move to the next stage of
recovery. Crisis intervention is the mainstay of disaster counselors, as it helps
individuals whose coping abilities have been overwhelmed by a stressful event.
Active listening and problem-solving are key tools for disaster workers, as they
establish a sense of respect and trust and better understand the survivor's
situation and needs.
SOCIAL SUPPORT
Social support networks can provide important affective and material aid
that mitigates the adverse effects of disaster trauma (van Ommeren, Hanna,
Weissbecker, & Ventevogel, 2015). Thus, mobilizing the natural social support
system of family, friends, the faith-based community, and coworkers can be
one of the most helpful interventions in the aftermath of a disaster
PSYCHOLOGICAL TRIAGE
Understanding the risk factors associated with Acute Stress Disorder (ASD) and Post-
Traumatic Stress Disorder (PTSD) is vital for effective intervention. The listed factors you
provided are commonly associated with an increased risk of developing these conditions:
● Loss of a loved one in the event

● Significant injury from the event: Physical injuries resulting from the disaster can
contribute to the development of psychological distress and trauma.
● Witnessing of horrendous image
● Dissociation at the time of the traumatic event
● Development of serious depressive symptoms within 1 week that last for 1 month or
longer
● Numbness, depersonalization, a sense of reliving the trauma, and motor restlessness
after the event
·
● Preexisting psychiatric problems
● Previous trauma
● Loss of home or community
● Extended exposure to danger
● Toxic exposure
● Absence of social supports, or traumatized social supports
MENTAL HEALTH REFERRAL
Disorientation—dazed; memory loss; inability to give date or time, state where he or she is, recall events of the past
24 hours, or understand what is happening.
Depression—pervasive feelings of hopelessness and despair, unshakable feelings of worthlessness and inadequacy,
withdrawal from others, inability to engage in productive activity.
Anxiety—constantly on edge, restless, agitated, unable to sleep, frequent frightening nightmares, flashbacks and
intrusive thoughts, obsessive fears of another disaster, excessive ruminations about the disaster.
Psychosis—hearing voices, seeing visions, delusional. thinking, excessive preoccupation with idea or thought,
pronounced pressure of speech (e.g., talking rapidly with little content continuity)
Inability to care for self—not eating, bathing, or changing clothes, inability to manage activities of daily life.
Suicidal thoughts or plans—expressing indirect or direct thoughts of harming self.
Other behaviors of concern—problematic use of alcohol or drugs, domestic violence, child abuse, or elder abuse.
ACUTE STRESS DISORDER
The characteristic of the disorder involves the onset of anxiety, dissociation, and other
symptoms within one month after a traumatic event, with a minimum duration of two days. If
these symptoms persist beyond four weeks following the trauma, it suggests a potential
diagnosis of Post-Traumatic Stress Disorder (PTSD).
● Sleep disturbance (e.g., difficulty falling or staying asleep or restlessness during sleep)
● Irritable behavior and angry outbursts (with little or no provocation), typically expressed
as verbal or physical aggression toward people or objects.
● Hypervigilance
● Problems with concentration
● Exaggerated startle response
POSTTRAUMATIC STRESS DISORDER
To be diagnosed with PTSD, an adult must have all the following for at least 1 month:
● At least one re-experiencing symptom

● At least one avoidance symptom
● At least two arousal and reactivity symptoms
● At least two cognition and mood symptoms
Re-experiencing symptoms include:
● Flashbacks—reliving the trauma over and over, including physical symptoms like a
racing heart or sweating.
● Bad dreams
● Frightening thoughts
PTSD IN CHILDREN
Children and teens can have extreme reactions to trauma, but their symptoms may
not be the same as adults. In very young children (less than 6 years of age), these
symptoms can include:
● Wetting the bed after having learned to use the toilet

● Forgetting how to or being unable to talk
● Acting out the scary event during playtime
● Being unusually clingy with a parent or other adult
CHILDREN AND YOUTH
When working with children, use direct and simple language that matches their
developmental level. Encourage them to express their feelings and ask
questions, as adolescents are more responsive to adult-like requests.
Recognize that children and adolescents may regress and educate parents
about normal reactions and reinforce these strategies for ongoing support.
OLDER ADULTS
Older adults may have faced past challenges and coped successfully, but they may
not have healed from stressors, making them more vulnerable to current stress. It's
crucial to assess preexisting physical limitations and assess the need to replace lost
equipment. Older adults may also have preexisting medical conditions and need
access to medication or supplies. Acknowledging their contribution to family and
community and framing assistance as an opportunity for community giving can
help. Recognizing and acknowledging the grief of lost sentimental items is
especially important for older adults.
INDIVIDUALS WITH MENTAL ILLNESS
Shelters often house many people with minimal privacy and noise, which can
exacerbate symptoms for those with preexisting mental illness. A Department of
Mental Health worker can identify these individuals, advocate for quieter
accommodations, and link them to their mental health providers. They can also
facilitate medication access if needed.
CULTURAL, ETHNICAL, AND RELIGIOUS SUBGROUPS
When working with individuals from cultural, ethnic, and religious subgroups, it's
crucial to be sensitive to family dynamics, recognizing the roles of family members,
particularly the head or decision maker. When using an interpreter, focus on the
person being spoken to rather than the translator. Additionally, consider the
significance of the community, acknowledging potential suspicion of outsiders and
the preference for help from within the community. Collaborating with community
support providers who have established relationships within these subgroups is
advisable.
WHEN GRIEF AND STRESS GO AWRY
Mental health services continue long after a disaster, addressing persistent

psychiatric symptoms in survivors. Diagnosing psychiatric disorders in the
aftermath is challenging due to disrupted daily functioning. Practitioners rely on
subjective reports and assess symptoms' impact on social, occupational, and daily
life functioning. Various disorders emerge post-disaster, including PTSD, adjustment
disorders, substance use disorders, major depression, complicated bereavement,
and generalized anxiety disorders. Marital discord (dissatisfaction in marriage) and
domestic violence may escalate. Children may experience depression, separation
anxiety, or conduct disorders. The passage of time, especially anniversaries, can
trigger distressing symptoms, emphasizing the importance of ongoing mental health
support.
TRAUMATIC GRIEF
Grief can be traumatic when linked to a sudden, violent loss or extreme emotional
distress, leading to overwhelming and unrelenting feelings. In cases of sudden or
violent death, individuals may experience a sense of unreality, guilt, and a need to
blame someone. Protracted medical or legal processes can impede the grieving
process. Profound feelings of helplessness may manifest, impacting emotions such
as sadness, worry, anger, and numbness. Treatment approaches include
antidepressants, psychotherapy, and medications like Prazosin for PTSD symptoms,
particularly nightmares. Exposure therapy, involving gradual and safe confrontation
of traumatic experiences through imagination, writing, or revisiting the location, can
assist individuals in coping with PTSD.
UTILIZING TECHNOLOGY AS AN ADJUNCT TO INTERVENTION
AND TREATMENT
The increasing use of technology in daily life presents opportunities to incorporate tools
and applications to support interventions and treatment. HelpGuide.org offers tips and
tools for managing stress and PTSD symptoms, including the "PTSD Coach" app, which
contains 17 tools. The app was created by the USDVA's National Center for PTSD in
partnership with the Department of Defense's National Center for Telehealth and
Technology. Another app, "Breathe 2 Relax," supports deep diaphragmatic breathing to
reduce the fight or flight response. The Federal Emergency Management Agency has an
app with safety tips and an interactive emergency kit list. The American Red Cross also
has an app available through digital media stores. These tools are not designed to
replace professional intervention but are easily accessible and can support adaptive
coping for those experiencing traumatic stress symptoms.
GROWTH AND DEVELOPMENTAL/COGNITIVE
CONSIDERATION
● Adequate support and internal resources enable most children to develop
coping skills for future adversities.
● Activities during sheltering or in disaster-safe houses, including age-
appropriate routines like singing, games, and dancing, help children feel
safe, promote a sense of normalcy, and maintain a routine.
11.
UNIQUE NEEDS OF CHILDREN
DURING DISASTERS AND
OTHER PUBLIC HEALTH
EMERGENCIES
EPIDEMIOLOGY OF PEDIATRIC INJURIES AND ILNESS DURING
DISASTERS AND PUBLIC HEALTH EMERGENCIES
Natural Disasters
Earthquakes
2010 Haiti earthquake (Gamulin et al., 2012):

● 471 pediatric patients out of 796 treated.
● 91% assigned to trauma group in the first 10 days.
● 88% required specialized orthopedic care.
2011 Japan earthquake and tsunami (Yonekura et al., 2013):
● Children accounted for over 6.5% of 19,000 dead and missing.
● Over 10,000 children evacuated near Fukushima No. 1 nuclear complex.
● 29.5% of disaster victims in field DMAT clinics were children.
2013 Lushan Earthquake (Jiang et al., 2013):
● 34 children under 14 admitted to West China Hospital.
● 67% had limb fractures.
● 29% had traumatic brain injuries.
Hurricanes/Tornados
Hurricane Katrina (August 2005):

● Category 5 hurricane hit Gulf Coast.
● Widespread displacement and destruction in Louisiana and Mississippi.
● Disrupted utilities, food distribution, healthcare, and communication.
● Followed by Hurricane Rita, worsening devastation.
● 400,000 individuals dispersed to 48 states, including 5,000 missing children.
● All missing children eventually reunited with parents.
Tornado in Tuscaloosa, Oklahoma (2011):
● Struck Tuscaloosa, Oklahoma.
● One adult hospital treated 800 patients, including 100 children, many unaccompanied and
unidentified.
● Children's hospital attended to 15 patients requiring significant neurosurgical interventions.
Floods
Global Warming Effects:

● Increased frequency of severe weather events, such as flooding.
● Example: Boulder, Colorado, experienced heavy rainfall of over 14.5 inches in less than 48
hours in September 2013.
● Prompted military helicopter evacuations of stranded children and their families.
● United Nations International Strategy for Disaster Risk Reduction
(UNISDR) Estimate (2015):
● Predicted 346 climate-related global disasters.
● Affected 98.9 million people.
● Resulted in 22,773 deaths.
PUBLIC HEALTH EMERGENCIES
The 1918 influenza pandemic, known as the Spanish flu, was a devastating public health crisis. In
the United States alone, it claimed the lives of 670,000 people within 17 weeks, with 25 million
others falling ill. Globally, between 21 and 40 million people died over a span of 10 months.
Contrary to typical flu patterns, the highest mortality occurred among individuals aged 15 to 40.
With no known cure, unconventional treatments were attempted, such as housing children on the
rooftop of New York City's Roosevelt Hospital, where they were exposed to cold, salty air. Despite
public outcry against the treatment's perceived cruelty, mortality rates reportedly decreased
among those subjected to it.
ACTS OF TERRORISM
● Terrorism often targets noncombatants, including children, with incidents increasingly

involving schools. Pediatric injuries and illnesses resulting from terrorism are prevalent. In
Turkey, studies have shown that children as young as 9 years old have been treated for
terrorism-related injuries, including penetrating chest injuries caused by bombs and open
globe injuries from mines and hand grenades. These incidents highlight the vulnerability of
children in terrorist attacks and the urgent need for measures to protect them.
● In 1995, tragic events unfolded in both Tokyo and Oklahoma City, impacting the lives of
children. In Tokyo, 16 children were exposed to sarin gas during a subway attack, thankfully
surviving without fatalities. However, in Oklahoma City, 19 children lost their lives in the
bombing of the Alfred P. Murrah Federal Building. The severity of injuries suffered by the
children in Oklahoma City was devastating, with many sustaining skull fractures, abdominal
injuries, amputations, and severe burns. While some children survived with nonfatal injuries,
the trauma of these events left a lasting impact on both communities.
ACTS OF WAR
Impact of War and Turmoil on Poor:
Slone and Mann (2016) study:

● Analyzed 35 studies with 4,365 young children.
Prevalence of:
● Posttraumatic stress disorder (PTSD).
● Behavioral and emotional symptoms.
● Sleep problems.
● Disturbed play.
● Psychosomatic symptoms.
Morbidity and Mortality in Displaced Pediatric Population:
Factors: War, famine, drought, or combination.
ACTS OF WAR
Predisposing Conditions:
● Overcrowding.
● Inadequate sanitation.
● Malnutrition.
● Lack of immunity to diseases.
Leading Causes of Morbidity and Mortality:
● Measles, diarrheal illness, upper respiratory infections, and malaria
Conditions in Refugee Camps:
● Unsanitary conditions.
● Disrupted infrastructures.
● Promiscuous defecation of children
Disproportionate Mortality Rates:
● Children under 5 years have higher crude mortality rates from infectious diseases
compared to older children and adults.
PSYCHOSOCIAL CONSIDERATION IN PEDIATRIC CARE
Disasters and public health emergencies are highly stressful events that can have long-lasting
effects. Children, in particular, are vulnerable to the challenges of evacuation, which may include
living in shelters and experiencing the loss of homes, schools, parents, pets, and loved ones. The
psychosocial impact of such events on children is influenced by factors like their developmental
stage, cognitive level, family's proximity and reactions to the disaster, and their direct exposure or
situation during the event (Conway, Bernardo, & Tontala, 1990). Furthermore, children’s
understanding of natural disasters may be influenced by their magical belief system, religious
beliefs, and level of moral development (Belter & Shannon, 1993). The parents and families of
children may die or become incapacitated and thus unable to care for their children, or children
and families may become separated in shelters or treatment facilities, leading to substantial
psychosocial problems (Cieslak & Henretig, 2003).
PEDIATRIC CARE DURING DISASTERS
The AAP Committee on Disaster and Emergency Medical Care made early efforts in addressing
pediatric needs during disasters in 1967-1968, publishing recommendations in 1972. These laid
the foundation for specialized pediatric emergency care. Following the September 11 attacks, the
National Commission on Children and Disasters was formed to address gaps in disaster
preparedness for children. Although legislation and efforts like the PAPRA of 2013 and NACCD
exist, communities and hospitals still struggle to fully integrate children into disaster plans, often
prioritizing pets over children.
PEDIATRIC DISASTER TRIAGE
In a natural disaster, children may constitute a proportionate number of victims based on the
community demographics. However, events in predominantly pediatric settings like schools or
daycare centers may lead to a higher proportion of child victims. Nurses must be prepared to
triage and treat children based on the severity of their injuries.
During disasters, hospitals often face patient surges with the first arrivals typically being the
walking wounded or those arriving by personal vehicle. Rapid assessment and triage are crucial,
as seen in the Aurora, Colorado mass shooting where law enforcement transported severely
injured patients to hospitals with little warning.
During a mass casualty event following an earthquake, triage faces challenges like multiple
scenes, limited resources, and delayed evacuation. Prehospital triage focuses on quickly
identifying and sorting patients, directing expedited transport to hospitals. The SAVE triage
system prioritizes resources for patients expected to benefit most from intervention based on
survivability and injury severity (Benson, Koenig, & Schultz, 1996).
PREHOSPITAL TREATMENT
During mass casualty events or disasters, prehospital care focuses on basic life support and
rapid transportation to definitive care. This involves rapid assessment of the patient's condition,
including airway, breathing, circulation, and neurologic status. Advanced life support measures
such as oxygen administration, fluid resuscitation, medication administration, and maintaining
body temperature are initiated at the scene or during transport to the hospital. Prehospital
personnel, trained at various levels such as Emergency Medical Technicians (EMTs) or
Paramedics (EMT-Ps), operate under state regulations dictating the extent of care they can
provide, including specific protocols for pediatric patients.
EMS and public safety responders are trained for mass casualty events, but their pediatric care
training is limited. Paramedics and EMT-Basics have minimal training in pediatric care, which can
be challenging during events involving many injured children. Consequently, EMS protocols
prioritize basic treatments in such situations.
PREHOSPITAL MEDICAL TRANSPORTATION AND EVALUATION
The decision to transport a child from a mass casualty or disaster scene depends on factors
such as the child's condition, available transportation resources, medical capabilities of the
personnel, and the desired destination. Ground transport is usually more accessible, but air
medical transportation may be necessary for critically ill children or when the distance to the
receiving facility is significant. Ambulance personnel or incident commanders make these
decisions based on the situation at the scene.
During events like fires or earthquakes that necessitate immediate hospital evacuation, patients
are moved to predetermined areas on hospital grounds. EMS responders and hospital leaders
then coordinate patient transportation to suitable facilities. However, such sudden evacuations
pose increased risks for children needing critical interventions. In these situations, nursing staff
responsible for the child's care must be ready to accompany them to the receiving facility to
ensure their safety.
EMERGENCY DEPARTMENT TREATMENT
Over 80% of all hospitals see children in the United States; however, most of these cases are
associated with minor injuries or conditions that can be managed without admission or transfer
to a pediatric specialty hospital. In emergencies associated with a number of critically injured
children, EMS protocols are designed to triage the sickest children to definitive care such as a
pediatric trauma center.
However, in a disaster or mass casualty situation, all hospitals will be called on to care for ill or
injured children of varying degrees of symptom severity. Therefore, all hospital EDs need to be
prepared to treat children; likewise, pediatric hospitals must be prepared to treat injured or ill
parents and adult family members. As part of their pediatric disaster planning, hospitals should
anticipate a lack of prehospital triage; establish protocols for care; create pediatric antidote kits;
organize and store pediatric equipment in one setting; and anticipate the need for extra personnel
(Hohenhaus, 2005)
COMMUNITY HOSPITAL PREPAREDNESS
Community hospitals play a vital role as the frontline responders in disasters, often facing the
immediate surge of patients within a short timeframe. To manage this influx, hospitals employ
rapid discharge protocols and expand their bed capacity. Regular disaster drills and participation
in mass casualty exercises are essential to prepare for such scenarios. However, hospitals
themselves may suffer damage, forcing closure and complicating patient care.
Effective disaster planning is crucial for hospitals to ensure they can adequately respond to the
needs of injured children. Tools like the EMS for Children Pediatric Readiness Project
Assessment Toolkit assist hospitals in assessing their capabilities and addressing gaps in
pediatric care. Assigning physician and nurse pediatric champions within each facility helps drive
ongoing improvements to enhance disaster preparedness over time.
CARE IN SHELTERS
In times of disaster, families may evacuate to shelters or seek refuge with relatives based on
various factors such as weather alerts or official advisories. Surprisingly, research shows that not
all families, especially those with children, may choose to evacuate, as evidenced by a study after
Hurricane Andrew. Healthcare and public safety professionals should recognize this possibility
and ensure alternative means of reaching families who may not evacuate. Furthermore, post-
disaster, families and children will require mental health services and counseling, with qualified
professionals needing to consider various factors including developmental levels, caregiver
support, and the nature and severity of the trauma.
LONG TERM CARE FOLLOWING A DISASTER
Large-scale disasters can lead to catastrophic health emergencies, overwhelming local

healthcare systems. Hospitals may face patient surges or structural damage, hindering their
ability to provide care. Healthcare providers may also be unable to fulfill their duties due to
personal injury or family obligations. Primary caregivers and medical practices may be disrupted,
affecting patients' access to care. Free clinics and emergency hospitals provide essential
immediate care, but reliance on them may delay the return of the local healthcare system to
normalcy in the long term.
EXPOSURE TO NUCLEAR AND RADIOLOGICAL AGENTS
Children, like adults, can be exposed to nuclear agents through an attack on a nuclear power
plant; they can be exposed to radiological agents through the release of a “dirty bomb” or an
unintentional release.
PREHOSPITAL TREATMENT
In the prehospital setting, detecting radioactive contamination is crucial, and Geiger counters or
dose-rate meters are used for quick detection. Pediatric advanced life support takes precedence
over radiation concerns, emphasizing the importance of saving lives over decontamination. EMS
personnel can remove contaminated clothing to eliminate much of the contamination. They must
wear protective gear and follow decontamination procedures, stabilizing life-threatening injuries
before decontamination. Separate facilities for decontamination should be established, with
provisions for infants and children to stay with their caregivers. Contaminated items are properly
disposed of or held for law enforcement, and open wounds should be covered until
decontamination is complete.
EMERGENCY DEPARTMENT TREATMENT
In preparation for the arrival of patients, the emergency department (ED) must set up patient care
areas to prevent the spread of radioactive contamination and establish security measures to
control access. Triage procedures include assessing radiation exposure levels, documenting
symptoms, and collecting tissue samples for biodosimetry. Children should receive age-
appropriate explanations of procedures to help alleviate fear and discomfort. Parents may be
kept away until life-threatening conditions are addressed and decontamination is complete,
although keeping them informed can help ease their anxiety. Hospitalization is advised for
patients with significant radiation exposure, illness, or trauma.
ETHICAL AND LEGAL CONSIDERATIONS IN PEDIATRIC
DISASTER CARE
EMTALA ensures that all individuals, including children, receive necessary medical screening and
stabilizing treatments upon arrival at a hospital's emergency department, regardless of their
ability to pay or parental consent. While efforts to locate parents are made, care cannot be
delayed or denied. However, transferring unstable patients or for economic reasons violates
EMTALA. During public health emergencies, all hospitals must assess and stabilize patients, with
no exceptions. The National Academies Institute of Medicine offers extensive guidance on crisis
standards of care, aiding decision-making during catastrophic disasters when resources are
limited. Their work provides frameworks and templates for various stakeholders to navigate
resource allocation challenges effectively.
PEDIATRIC DEATH FOLLOWING DISASTERS AND PUBLIC
HEALTH EMERGENCIES
In the aftermath of disasters, children are tragically affected by injuries and illnesses, often
resulting in fatalities. The scale of mass casualties overwhelms both parents and healthcare
workers, who may be unprepared to handle such devastation. Events like bombings, tsunamis,
and hurricanes underscore the profound impact on children, leaving many orphaned or displaced.
Nurses and healthcare workers, despite facing personal losses, continue to provide care amidst
chaos.
In emergency settings, despite efforts, children may pass away. Allowing parental presence
during resuscitation can be beneficial, but challenges arise in disaster scenarios. The Emergency
Nurses Association advocates for parental presence, acknowledging its benefits. However,
providing support for grieving families during disasters is difficult due to limited resources.
Guidelines exist for healthcare professionals, but their implementation in mass casualty
situations requires careful planning and discussion.
PLANNING FOR DISASTERS PEDIATRIC SPECIFIC CONSIDERATIONS
Disaster planning must consider the specific needs of children across all phases of the disaster
cycle. While complete protection from disaster impact is impossible, efforts during mitigation
and planning can mitigate the effects on children. National initiatives, starting in 1995, have
aimed to enhance children's care during disasters, with key agencies setting seven goals to
address their needs.
PEDIATRIC CONSIDERATIONS IN HEALTHCARE PREPARATIONS
Nurses and healthcare professionals face challenges in caring for pediatric patients during
disasters. They may lack pediatric care experience and struggle with medication dosages.
Familiarity with disaster relief agencies is essential. Disasters like the 2004 tsunami and
Hurricane Katrina can worsen healthcare shortages. Nurses provide crucial mental health support
post-disaster, aiding children in expressing fears and creating safe spaces for recovery and skill
development.
EQUIPMENT
Standards and guidelines exist for prehospital and in-hospital pediatric emergency care, including
minimum equipment lists provided by organizations like the Emergency Nurses Association and
the American Academy of Pediatrics. Pediatric equipment systems, such as color-coded tapes,
help estimate equipment size and medication dosage based on a child's length, reducing errors
and saving time during emergencies. Clinical trials have shown significant reductions in errors
when using these devices, making them valuable tools for emergency care professionals,
especially those less familiar with pediatric care who may be called upon during disasters or
public health emergencies.
EDUCATION
Nurses and healthcare professionals play a crucial role in caring for children during disasters or
public health emergencies. To enhance their preparedness, participation in hospital exercises and
training programs is vital. One such program is the Pediatric Disaster Life Support (PDLS) course,
which focuses on meeting the physiological and psychological needs of children post-disaster.
Other training options include pediatric life support and advanced pediatric life support courses
for emergency healthcare professionals, as well as courses like Pediatric Education for
Prehospital Professionals (PEPP) for EMS personnel. School nurses can also benefit from
courses such as Managing School Emergencies offered by the National Association of School
Nurses. These educational opportunities ensure that healthcare professionals are equipped to
provide optimal care for children in crisis situations.
12.
DISASTER NURSING IN SCHOOLS AND
OTHER COMMUNITY CONGREGATE TO
CHILD CARE SETTINGS
GROWTH AND DEVELOPMENTAL/COGNITIVE
CONSIDERATION
● Children's vulnerability in disasters stems from their lack of experience, skills,
and resources to independently handle traumatic events, making it important
to focus on their emotional, social, and developmental needs.
● Instead of therapy, children require community-based, developmentally
appropriate activities to restore a sense of safety and hope, ensuring a healthy
recovery. Traumatic events during disasters can lead to varying degrees of
behavioral symptoms in children, with psychological adjustment ranging from
transient reactions to severe, prolonged responses, including posttraumatic
stress disorder (PTSD).
● About 16% of children exposed to traumatic events worldwide develop PTSD,
with cognitive and emotional responses such as anger, rumination, avoidance,
and dissociation contributing to the risk of PTSD development.
ELEMENTARY AND SECONDARY SCHOOLS
● Children, both with and without disabilities, may struggle to make critical decisions during
emergencies.
● School superintendents often have response plans, but fewer have plans for prevention,
evacuation, or disaster provisions for children with special healthcare needs.
● Urban school districts tend to be better prepared than rural districts.
● Children with disabilities are particularly vulnerable in disaster situations, necessitating
national disaster preparedness standards for all facilities caring for children.
● Formalized disaster plans, especially for young children and those with disabilities, should
be practiced routinely.
● The National Commission emphasizes addressing problems in school disaster preparedness
plans.
● Recommendations include sensitivity to language and cultural needs when working with
diverse families, avoiding placing child interpreters in stressful roles.
Preparedness
● The National Commission on Children and Disasters emphasizes the
need for federal and state support to protect children during disasters
and reunification with families.
● 62% of school districts face challenges in implementing emergency
plans, citing issues like lack of trained staff, equipment, and practice
with first responders.
● Schools are recommended to conduct vulnerability assessments,
considering functional access limitations and the needs of students
with disabilities during preplanning.
● Federal and state funding should be sought during preplanning to
acquire resources and create disaster-safe rooms on school
campuses.
Preparedness
● Some school districts in rural Arkansas incorporate "safe rooms" in
their emergency plans, utilizing volunteer fire departments during
tornado warnings.
● Continuous monitoring of the unique needs of children in academic
settings is essential, ensuring equitable access to all students
following a disaster.
● Nurses in schools should prioritize the needs of all children under their
care and stay informed about current disaster preparedness
recommendations.
● Administration should involve nurses in disaster-planning committees
to ensure ongoing preparedness on campus.
Preparedness
Examples of how nurses can contribute to disaster preparedness in school

settings include:
1. Nursing students collaborating with school nurses to assess disaster
preparedness in local schools and assisting in plan development as a
community health nursing project.
2. Nurses and nursing students volunteering for vulnerability assessments,
focusing on functional access requirements and addressing the needs of
students with disabilities.
3. Offering services to disaster organizations, like the American Red Cross or
state emergency management offices, with properly trained nurses ready
to deploy during disasters or public health emergencies.
Response
● The psychological impact of disasters can be severe for both children and adults,
leading to disruptions in basic services, homelessness, and transportation
issues.
● Children, influenced by adult anxiety, often experience magnified grief responses
after disasters.
● Emotional trauma is expected post-disaster, and healthcare professionals are
trained to assess subtle behavior changes in children indicating poor coping, but
teachers and school administrators lack such training.
● "Psychological first aid" involves recognizing and responding to emotional needs
post-disaster, but school personnel receive limited training in this aspect.
● School-based settings must have qualified professionals providing emotional
first aid during the response phase, and personnel should be aware of
community mental health resources in emergency plans.
Response
● Long-lasting mental and physical effects in children post-disaster
necessitate collaboration with community-based nurses and mental
health professionals for monitoring PTSD, behavioral issues, anxiety,
and depression.
● The National Commission recommends developing mental health
training tools for teachers, implementing statewide training
requirements, and incorporating crisis support into
certification/recertification processes.
● While teachers should recognize basic pediatric mental health issues,
they shouldn't provide treatment. Instead, schools should ensure
trained mental health professionals are available to treat students on
campus post-crisis.
Recovery
● School disaster plans should aim to be one-stop resource zones for
necessary mental and physical health services during the recovery phase.
● Tracking and reunification procedures, including encrypted external hard
drive storage of directory information, are essential in emergency
preparedness plans.
● Communication during disasters is crucial, with schools urged to have
HAM radios, satellite phones, emergency text alerts, and updated websites
in their disaster plans.
● Regular practice of emergency disaster plans, including reunification
processes, with local first responders is essential for faculty, staff,
students, and families to ensure quick and effective responses during
emergencies.
CHILD WELFARE AGENCIES
Preparedness
Continuity of Operations Plan (COOP) for disaster management must integrate
the needs of all supervised children, addressing components outlined in the
Child and Family Services Improvement Act of 2006 and recommendations
from the Justice Working Group on Children and Disasters.
1. Coordinate management with federal, state, and local agencies.
2. Educate staff members about their roles during a disaster and how to
carry out the plan.
3. Identify, locate, and continue availability of services for children under
state care or supervision who are displaced or adversely affected by disaster.
4. Respond to new welfare cases in areas adversely affected by a
disaster and provide services.
Preparedness
5. Remain in communication with caseworkers and other essential child
welfare personnel who are displaced because of disaster.
6. Preserve essential program records.
7. Continue funds for children and families during the recovery of a
disaster.
8. Coordinate services and share information with other states.
• Child welfare agencies, in collaboration with juvenile and family
courts, child advocates, volunteers, and community resources, must take a
leadership role in developing disaster planning and COOP.
Higher Standards and Best Practices:
1. Provide annual staff training, including plan implementation.
2. Coordinate with emergency management services to integrate child
welfare disaster plan and COOP with other local and state plans.
3. Collaborate with stakeholders to implement COOP training and drills
Preparedness
4. Develop a plan to address the high emotional needs of children after a
disaster.
5. Require best practice emergency planning for all entities in child welfare.
6. Implement the state plan at local levels and integrate local plans into the
state plan.
Recommendations by the National Commission on Children and Disasters:
• Perform a gap analysis for involved agencies, assessing shortcomings
and best practices.
• Develop a training program to assist agencies in plan implementation
and ensure staff knowledge of their roles.
• Coordinate and support management and review of the COOP with
state emergency management teams and key stakeholders.
Response
● Agencies must conduct drills to considering the unpredictability of
disasters.
● Drills involving young children should be age-appropriate, considering
potential emotional distress from theatrical makeup or dramatic
injuries.
● Drills should be carried out in various scenarios, including when not all
essential participants are present on-site, emphasizing the need for
"rigid flexibility."
● Thorough intake procedures should be in place for assessing client
and family needs after a disaster, promoting normal functioning and
recovery.
Recovery
Workload Considerations:
● Assess potential workload on existing employees during and after disasters.
● Account for employees unable to report to work due to the disaster.
● Minimize confusion within collaborating agencies, especially related to
welfare jurisdiction.
Staff Well-being:
● Consider mental health needs and support systems for staff during recovery.
● Address compassion fatigue among workers, offering ongoing support,
debriefing, and mental health treatment.
● Develop agreements with specific health professionals to fill healthcare
gaps.
● Conduct educational opportunities for healthcare providers on mental health
issues.
Recovery
Physical Healthcare Coordination:
• Coordinate physical healthcare needs for clients and families during disasters.
• Ensure treatment options for nutritional, injury prevention, wellness, illness, and
sleep/rest.
• Address special dietary needs and provide a safe environment in new settings.
Housing Initiatives:
• Take action to find adequate housing for clients and families.
• Communicate with local schools regarding transportation for displaced children.
• Establish backup plans with surrounding areas for foster parents, supporting
them during and after disasters.
Post-Disaster Evaluation:
• Hold debriefing sessions at the end of the response and recovery phases.
• Assess the effectiveness of the COOP and make necessary changes or updates.
• Communicate changes transparently and train the entire agency accordingly.
• Routinely review and drill the COOP at least annually.
JUVENILE JUSTICE AND RESIDENTIAL SETTINGS
• In 2015, over 48,000 juvenile offenders were placed in facilities outside
their homes nationally.
• There is a lack of a comprehensive national disaster plan for the care,
welfare, and recovery of children in non-home-based facilities during and after
disasters.
• Federal law doesn't mandate juvenile justice systems to develop and
implement disaster plans, unlike state child welfare agencies.
• The absence of child-sensitive disaster plans for juvenile offenders
raises concerns about their unique emotional and judicial needs during disasters.
• Children in the juvenile justice system often enter as victims of past
traumas, contributing to delinquent acts and requiring special attention.
• During disasters, court records may be destroyed, leading to the
potential placement of juvenile offenders in adult detention facilities, posing
further risks.
Preparedness
• The juvenile justice system must establish a clear plan for the care,
safety, and recovery of children in disastrous situations while upholding their
rights.
• Numerous interconnected agencies, including prisons, law enforcement,
detention centers, probation officers, and more, are involved in the juvenile justice
system, making collaborative disaster planning a monumental task.
• The National Commission on Children and Disaster Report (2010) puts
forth recommendations for state and local juvenile justice agencies, emphasizing
the need for comprehensive disaster plans, with support from the Department of
Homeland Security/Federal Emergency Management Agency (DHS/FEMA) and
the Department of Justice (DOJ).
• The U.S. Department of Justice, Office of Justice Programs (2011),
responds to the 2010 report with a comprehensive guide, "Emergency Planning
for Juvenile Justice Residential Facilities," aiding individual residential facilities in
Response
• Professional nurses can play a crucial role in disaster planning for
children in the juvenile justice system by advocating for their rights, educating
fellow nurses, participating in community organizations, and being disaster
preparedness educators.
• Nurses working in agencies housing juvenile justice populations have
specific responsibilities, including providing disaster preparedness education,
practicing the disaster plan, ensuring record protection, protecting the general
population from potential harm, and providing post-disaster care.
• An example from Hurricane Harvey in 2017 showcases a well-executed
disaster plan at the Victoria Regional Juvenile Justice Center, emphasizing the
importance of evaluating inmates, transporting them to safe facilities, and
addressing the anxieties and challenges faced by both staff and juveniles during
evacuation.
CHILD CARE SETTINGS
• The U.S. has over 400,000 licensed child care facilities, including
child care centers, small and large family child care homes, and other
types.
• Thousands of unlicensed child care programs exist, administered
by religious organizations, the military, or government entities.
• In emergencies or disasters during child care hours, children rely
entirely on programs for protection.
• The denial hindered families' ability to address property damage,
apply for disaster benefits, find housing and employment, and rebuild
their lives.
• Providing child care during disasters is crucial for families and
individuals engaged in relief efforts, ensuring a safe setting for children.
Preparedness
• The National Commission Report (2010) recommends
state child care regulatory agencies include planning, training, and
exercising in health and safety standards, coordinating statewide
plans with emergency managers.
• Child care centers should have the freedom to create their
disaster plans while meeting minimum standards, encouraging
parental input and regulatory agencies to provide examples.
• The American Red Cross Masters of Disaster plan for
grades K–8 could serve as a template for child care centers,
emphasizing developmentally appropriate interventions and
regular practice drills.
Response
• The Head Start Emergency Preparedness Manual (2015) advises creating a
detailed decision tree for staff during disasters, covering evacuation procedures, ensuring
preschoolers' basic needs, and notifying parents for reunification plans.
• Emphasizes the potential relief provided by a well-known, written plan for
contacting parents or guardians during disasters.
• Recommends collaborative agreements with external agencies (churches, Red
Cross, schools) to prearrange assistance for affected child care centers.
• Advocates for crucial methods to identify children in child care settings,
proposing the use of armbands or picture ID badges with scan cards containing contact
information.
• Anticipates the need for temporary (make-shift) child care centers post-disaster,
serving regular clients, workers, and volunteers with children supporting ongoing volunteer
efforts.
• Acknowledges challenges in temporary disaster child care meeting minimum
regulatory standards and suggests regulatory agencies consider exemptions in the
immediate aftermath if the shelter meets the highest possible standards.
Recovery
● Recommends Congress and federal agencies enhance capacity for child care services post-
disaster, focusing on the immediate aftermath and recovery stages.
● Highlights the widespread destruction of permanent structures during disasters, affecting
homes, businesses, schools, and child care centers.
● Stresses the importance of rebuilding these structures for community recovery, allowing
parents to return to work and others to rebuild homes or businesses.
● Emphasizes the vital role of child care during the recovery stage for overall community
recovery.
● Calls for preemptive federal and state policies providing emergency funding and
reimbursement for child care during the recovery stage.
● Advocates for proactive community planning, encouraging churches and community groups
to develop written plans for supporting community recovery after disasters.
● Recognizes the critical role of mental health in disaster preparedness and recovery,
especially for children who depend on parents or guardians for survival.
● Commends the American Red Cross's practice of keeping families together in shelters after
disasters, improving overall mental health by allowing parents to care for their children.
UNIVERSITIES/COLLEGES
Universities and colleges have a diverse student population,
including those under 18. Adolescence, the period between
childhood and adulthood, lacks a universally defined age
boundary. Postsecondary students often fall within the middle
(14–18) to late (19–24) adolescent range in terms of physical,
cognitive, and socio-emotional development. While adjusting to
the demands of college can be challenging, older adolescents
exhibit enhanced independent function, critical thinking abilities,
heightened concern for others, and improved emotional stability,
as stated by the American Academy of Child and Adolescent
Psychiatry in 2015.
THE COLLEGE/UNIVERSITY ENVIRONMENT
IHE Commitment to Safety:
● Every IHE is committed to ensuring the safety and welfare of individuals on campus, providing policies,
procedures, and strategies for a safe environment.
Challenges in Campus Characteristics:
● College and university campuses resemble small towns or cities, covering large areas with various services.
● Challenges include access control, monitoring movements, defining boundaries, standardizing procedures,
decision-making, and resource allocation.
Complex Governance Structure:
● IHE governance is complex and decentralized, potentially hindering quick decision-making during crises.
Open Access and Community Integration:
● Most IHEs have open access and are integrated into surrounding communities.
● Students are dispersed across various facilities, including residential areas for out-of-state, international, and
married students.
Fluctuating Campus Population:
● Unlike secondary education, IHEs serve primarily adult students, but the population is in constant flux, changing
daily, semesterly, and yearly.
● Commuting, virtual classes, and diverse student demographics contribute to a dispersed population.
Impact on Emergency Planning:
● These factors significantly influence how IHEs plan, respond to, and recover from emergencies at the campus or
community level.
STUDENT HEALTH CONCERNS
College students, considered legal adults, face distinctive health challenges,
and the complexity is heightened by HIPAA and FERPA regulations. Survey
results indicate that 95% of college counseling center directors express growing
concern about students with significant psychological problems, with anxiety
topping the list (41.6%), followed by depression (36.4%) and relationship issues.
A considerable percentage (24.5%) of clients are on psychotropic medications,
and 21% present severe mental health concerns. These factors are crucial
considerations in planning the recovery phase of post-emergency situations.
Despite mental health challenges, young adults are recognized as valuable
volunteers during disasters due to their capability in participating across
preparedness, response, and recovery phases. The recommendation is for
colleges and universities to leverage the strengths of their students by educating
them about disaster preparedness and involving them in developing emergency
plans.
EMERGENCY PLANNING GUIDELINES
• Engage in or create a local or regional long-term recovery organization.
• Develop centers for community engagement and/or centers for teaching and
learning that lift up service and civically engaged pedagogies (e.g., service learning).
• Partner with the American Red Cross to provide emergency shelter.
• Contact (if religiously affiliated) a denominational disaster response organization
to explore partnerships.
• Create and train a student-led Rapid Response Team that can function until
official responders arrive.
• Organize students into teams to assess campus buildings for disaster
preparedness and share their results with campus staff.
• Develop a campus response plan (focusing on assistance, not just recovery).
• Develop emergency communication strategies, such as cell phone or text
message alerts.
• Integrate the campus plan with local and regional response plans.
• Put in place risk-management policies to enable an informed, safe, and quick
response.
Prevention
Steps to identify risk reduction strategies that prevent potential incidents
and identify actions that will mitigate the impact of an actual emergency,
such as:
• Form behavioral intervention teams to decrease the risk of acts
of violence.
• Develop exposure policies and procedures during public health
outbreaks.
• Determine evacuation routes when students must leave buildings
or other areas of campus.
• Develop plans and collect supplies to allow students and staff to
shelter-in-place.
Preparedness
Tips for students listing suggestions for developing their own “disaster plans”
• Be aware of the types of emergencies/hazards that can potentially
affect your area of residence.
• Plan a meeting with your family, roommates, and coworkers to
discuss disaster preparedness.
• Determine how you will exit your apartment, dorm, or house in case of
an evacuation. Know at least two ways to get out.
• Plan for several different meeting places. One should be directly
outside your living space. The other should be a site away from your
neighborhood in the event you cannot return home. Give your family members
and roommates a copy of this information.
• Choose an out-of-state contact person. It is often easier to call long
distance than locally during an emergency situation.
Preparedness
• As soon as possible, let the designated person know you are safe.
Share this contact person’s information with your family and roommates.
• Discuss how to “shelter in place.” The type of incident will
determine how you should shelter.
• Discuss and practice how to turn off electricity, water,
heating/cooling systems, and gas.
• Assemble a disaster supply kit for at home, at work, and in your
vehicle (recommended by the Red Cross).
• Take a course in first aid and cardiopulmonary resuscitation (CPR).
Response
• Lessons from events like Hurricane Katrina emphasize the need to
include international students.
• Responses include decreased interest in activities, risk-taking
behaviors, physical complaints, and PTSD.
• Young adults can respond with resilience and contribute actively
during disasters.
• Tulane University has a detailed plan for responding to
flooding/evacuation situations.
• Utilizes multiple communication methods, including an emergency
notices website and text messaging.
• Demonstrates the importance of proactive measures in disaster
preparedness for higher education institutions.
Recovery
• Goal: Restore the learning environment, meet affected people's
needs.
• Involves decisions in collaboration with community, state officials,
and partners.
• Restoration may include housing, off-site classes, and online
learning.
• Crucial to communicate decisions promptly to media, faculty, staff,
students, and families.
• Identify mental health resources for short- and long-term services
on and off campus.
• Leadership support and collaborative partnerships are critical for
successful planning.
• Community nurses play a vital role in providing expertise and
CHURCHES/PARISHES
• Churches are valuable community resources during crises.
• Emphasizes the importance of considering children in disaster
preparedness.
• Guidelines for children in churches, including those with schools
and care facilities.
Preparedness
• Encourages churches to follow guidelines from credible sources
like Red Cross.
• The Southern Baptist Convention has a long history of
collaborating with the American Red Cross, the Salvation Army, and other
organizations to provide mass feeding and sheltering prior to, during, and
after disasters.
Response
• Highlights churches as ideal disaster shelters with suitable
facilities.
• Describes key features such as large halls, accessibility,
showers, bathrooms, and kitchens.
• Highlights churches as ideal disaster shelters with suitable
facilities.
• Describes key features such as large halls, accessibility,
showers, bathrooms, and kitchens.
Recovery
• Describes how families often turn to their community churches for solace after
a disaster.
• Acknowledges the challenge if the church structure is damaged, prompting the
need for identifying alternative service locations.
• Notes media portrayal of religious services in church parking lots with the
damaged church in the background.
• Highlights the potential for disasters to strengthen the unity among church
members.
• Mentions the supportive outreach from other churches, offering comfort,
donations, shelter, and the use of their facilities during the rebuilding phase.
• Observes that churches nationwide, regardless of size or denomination, gather
donations to aid damaged churches.
• Suggests that post-rebuilding, churches may be more motivated to develop
disaster plans, gather supplies, and educate members for future preparedness.
• Encourages active involvement of children in the rebuilding and recovery stage,
potentially taking on leadership roles in these efforts.
13 .
Care of the pregnant
woman and newborn
following a disaster
CHAPTER OVERVIEW
Pregnant women and infants face unique health
challenges in the aftermath of natural disasters,
epidemics, or terrorist events. Issues include disruptions
in clean water supply, limited access to safe food,
exposure to environmental toxins, interrupted healthcare
access, shortages of life-sustaining medicines, and
crowded shelter conditions.
PHYSIOLOGY OF NORMAL PREGNANCY
● Pregnancy is a natural but cimplex state of health.
● Hormone levels increase significantly causing nusea and vomiting.
● Many changes in hormones impact pregnancy.
● Human choriogonadotropin (HGG) rises early in pregnancy.
● Relaxin rises and “relaxes” ligaments, increasing pelvic mobility that may lead to
aches in the back and hips.
● Circulatory changes occur because the expectant mother’s blood volumen increase
by 3.0 L with an additional 3.5 L of water in the amniotic fluid, the fetus, and the
placenta.
● Increase body weight is required to supoort fetal growth and development.
● Women should eat a balaced diet, avoiding processed, high salt, and high sugar
foods.
● Rest is essential for pregnant women.
What are the critical reproductive healthcare messages for
women and their healthcare provides?
Pregnancy Awareness
● Half of all pregnancies are unplanned; women may not be aware they
are pregnant and that they have special healthcare needs.
● Pregnancy testing must be available to confirm suspicions of
pregnancy when there is doubt;
● All pregnant women should receive prenatal care.
● Mass vaccination or prophylaxis must consider the special
circumstance of oregnancy;
WHAT ARE THE CRITICAL ISSUES FOR PRENATAL
CARE?
General Considerations
● Records from prior prenatal care may not be available;
provides may have to “start from scratch”. Consider giving a
copy of prenatal records to patients if care is likely to be
episodic or the woman is likely to be transient.
● During the First Trimester (before 13 weeks)
● During the Second Trimester (from 13 to 26 weeks)
● During the Third Trimester (from 24 weeks to term [greater
than 37 weeks])
WHAT SIGNS AND SYMPTOMS REQUIRE
EMERGENCY OBSTETRIC SERVICES?
Seek emergency obstetric care for the following:
● Preterm (less than 37 weeks) contractions
● Contractions every 10 minutes or more (cramping)
● Pelvic pressure
● Low, dull backache
● Abdominal cramps with or without diarrhea
● Regular painful uterine contractions at term (increasing in frequency and
durations)
● Vaginal bleeding and/or severe abdominal pain
● Leakage of fluid(obviousorsuspectedrupturedmembranes)Decreased
fetal movement
COMPLICATIONS OF PREGNANCY
Hypertension, pregnancy-Induced Hypertension,
and Eclampsia
-Hypertension in pregnancy has been classified
into four types: preeclampsia/eclampsia, chronic hypertension,
chronic hypertension with superimposed preeclampsia, and
gestational hypertension.
PIH ( Pregnancy-
Hypertension induced
Hypertension
PIH used to be called

Is when the pressure in “preeclampsia.” PIH can
your blood vessels is lead to toxemia or
too high (140/90 seizures. PIH is known
mmHg or higher) It is to be more common in
common but can be first pregnancies and a
serious if not treated. complex response
involving hypertension.
Diabetes Mellitus Bleeding Disorders in
Pregnancy
Diabetes of pregnancy
Placenta previa is a condition
(gestational diabetes)
where the placenta grows
impacts 3% to 5% of pregnant
over the cervix. The classic
women. Essentially, it is a
symptom is painless bleeding.
“carbohydrate intolerance
Under no circumstances
during pregnancy” further
should a vaginal exam be
challenged by the need of the
done should a previa be
pregnant woman to consume
suspected as it can cause
more calories, which puts
severe hemorrhage.
increased demands
on the pancreas.
OTHER MEDICAL CONDITIONS
IN PREGNANCY OCCURING
DURING A DISASTER
Pregnant women may

Idiopathic experience other disaster-
thrombocytopenia related medical conditions
purpura (ITP) is a unrelated to their pregnancy.
decrease in platelets. These conditions should be
It can be treated with treated as soon as possible
steroids in pregnancy. and may include
trauma/fractured bones.
ASSESSMENT OF THE PREGNANT
WOMAN AND BABY
Mother: vital signs: heart rate, blood
pressure, respirations
Baby: fetal heart rate and patterns,
baby’s position (head
down or vertex presentation preferred)
● CARDIOVASCULAR SYSTEM
-It is very important to identify any early signs of
hypertensive states and to intervene immediately. Nursing
assessment includes monitoring the pregnant woman’s
blood pressure, checking a radial pulse, and listening to
heart sounds. During a disaster, the nurse may need to
improvise equipment and remain vigilant for complaints of
headache, visual changes, and epigastric pain.
● CHILDBIRTH DURING DISASTERS
-During a disaster, supplies and equipment that are
normally used during labor and birth may not be available.
STAGES OF CHILDBIRTH
There are three stages of childbirth, which are as follows:
● First Stage (Can Last up to 20 Hours)

-Phase 1 (early labor)- with cervical dilatation fro 0 to 4 cm.
-Phase 2 4 to 8 cm (active phase)-contractions are 3 minutes apart and last at least 45 secs.
-Transition 8 to 10 cm (full dilatation)-this is the most difficulty time in labor, requirung
additional support and comfort.
● Second Stage: Birth
-This stage involves the passage of the baby through the birth canal.
● Third Stage: Delivery of the Placenta
-When managing or assisting at birth, keep the mother calm and comfortable, maintain
clean hands and wear gloves, prepare a bed for delivery (cover it with plastic or a shower
curtain), coach the mother through pushing, assess the newborn to ensure breathing on
delivery, and cut the cord when it stops pulsating.
COMPLICATIONS OF LABOR AND
DELIVERY: MALPRESENTATION
● During childbirth, it is best if the head emerges first. This is a vertex
presentation. The head is usually the largest part of the baby’s body.
● Other malpresentations include shoulders and feet. In a “footling
breech,” the feet come out first. This is more common in a very
preterm birth.
● ‘Back labor” occurs when the fetus’s back is lying against the
mother’s back. During each contraction, the mother may experience
significant back pain. A posterior delivery is more challenging to get
the face-up baby around the pelvic bones and out of the mother.
CARE OF UMBILICAL CORD
● The umbilical cord is the fetus’s lifeline during
pregnancy and delivery.
● After delivery, once the cord has stopped
“pulsating,” the cord should be clamped with a
sterile clamp or umbilical tape. Leave about 6
inches of cord next to the baby. A second clamp
should be placed near to clamp off the placental
blood.
Physiology of Postpartum Mother and Newborn
Major Considerations Postdelivery
● SPECIAL ASSESSMENT/CONDITIONS OF THE NEWBORN
● POSTPARTUM MANAGEMENT IN DISASTERs
-Unless the mother or baby is critically ill, it is best to keep the mother
and baby together. The mother/baby dyad is the standard for care.
● SPECIAL CONSIDERATIONS FOR MOTHER AND BABY IN DISASTERS
-Women who give birth and the infants to whom they give birth during
disasters will have higher rates of complications than those during
nondisaster periods.
● INFECTIONS AND COMMUNICABLE DISEASES
-Prevention of infection is key to perinatal care. The most important
intervention to prevent infection is handwashing, a fact that cannot be
overemphasized.
Special Infectious Disease
Considerations
● Varicella (chickenpox):
● Meningococcal meningitis
● H1N1 (influenza)
● Influenza
● Pandemic flu
● Tuberculosis
● Thrombophlebitis
● Pyleonephritis
ENVIRONMENTAL CLEANLINESS
AND SANITATION
BIOTERRORISM
-A bioterrorist event or a naturally emerging infectious disease outbreak creates additional
challenges for the protection of the pregnant woman and fetus. Assessments for exposure to
the pathogen as well as the need for vaccinations and/or treatment should be conducted as
soon as possible.
TRAUMA IN PREGNANCY
-There is a huge challenge in caring for women following a terrorist event: assessment and
treatment of the trauma patient and treatment of the pregnant woman.
Performing Cardiopulmonary Resuscitation
-When planning a trauma response, it is important for all providers to be familiar with the
modifications in performing cardiopulmonary resuscitation (CPR) on pregnant women.
BREASTFEEDING AND INFANT NUTRITION
-Promoting breastfeeding is always best for mothers and babies, and never more important
than during a disaster.
Breastfeeding Challenges
-There are numerous challenges for successful breastfeeding after disaster.
LACK OF FOOD, MALNUTRITION, AND STARVATION
-The availability of safe water and food is essential to survival after a disaster.
CRISIS CONDITIONS ASSOCIATED WITH PREGNANCY
-Profuse bleeding can occur after the infant is born and the
placenta is delivered most often from a relaxed uterus that has not contracted.
SHELTERS AND PRACTICAL CONSIDERATIONS
FOR AUSTERE ENVIRONMENTS
● All shelters must be prepared to meet the needs of pregnant women and families with
infants. These requirements include:
● A plan to provide prenatal care and well-baby services at the shelter
● A plan to ensure access to a safe environment for safe delivery
● Plans to keep families and infants together and reconnect with families and infants
● An identification system for women and children using ID bracelets
● Health and hygiene needs for mothers and infants and pregnant women that include:
● For babies: ready-to-feed formula, diapers, premature diapers, pacifiers, infant clothes,
and breast pumps
● For mothers: sanitary napkins and clean underwear
● Necessary furniture and equipment such as cribs, strollers,and car seats
● Emergency birth kits
DEATH OF THE MOTHER OR INFANT—BEREAVEMENT
CONCERNS AND INTERVENTIONS
Maternal Death
-The death of a pregnant woman or new mother is not acceptable in our society. Sudden death of a
woman in the perinatal period may be due to:
● Pulmonary or amniotic embolism. Treatment of these life-threatening complications is
supportive; supporting cardiac and respiratory function.
● Infection. Prevention is key, using handwashing, and a clean environment and technique.
● Bleeding. Should the mother experience a life-threatening bleeding emergency (e.g., placenta
abruption), it may lead to DIC.
● Accident. Unexpected death in a disaster.
Perinatal Death
-The death of a fetus or newborn, through miscarriage, fetal demise, stillbirth, or neonatal death, is a
devastating, life-changing experience. Pregnancy loss is much more common than maternal death.
Even if the pregnancy was early, the mother and her significant others may experience grief.
Healing Professional Interventions in Maternal/Perinatal Bereavement
-Should a mother and/or her baby die during a disaster, the caregivers should acknowledge the
losses, giving value to the life, even if yet to be born.
RETURNING HOME SAFELY
The postpartum woman and newborn must take precautions to stay safe during and after a
disaster or emergency event.
Flood Water in Streets and Buildings
-Flood water may contain harmful substances such as chemicals, gasoline, or bacteria that
could cause serious disease. It is best if children and pregnant women avoid touching or
walking in flood water. If individuals do touch the water, they should use soap and clean water
to wash the parts of the body that came in contact with it.
Toxic Exposures During Pregnancy
-If a pregnant woman is worried that she may have been exposed to dangerous chemicals or
substances during or following the disaster, she should be encouraged to talk to a healthcare
provider.
Returning Home
-Pregnant women may face several possible dangers when returning home, depending on their
individual circumstances and the damage to their homes. I
RISK OF VIOLENCE, ABUSE, SLAVERY, AND HUMAN TRAFFICKING
-In disasters, large populations of people may be displaced. Vulnerable populations,including
women, teens, and children are at higher risk of abuse following disasters.
POSTTRAUMATIC STRESS DISORDER

-Experiencing a traumatic event such as disaster is a precipitating factor for developing PTSD

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SECTION II: DISASTER

MENTAL HEALTH AND

Preparedness: Getting ready to respond before the disaster happens.

Mitigation: Doing things to reduce the impact of future disasters.

Nurses can play a big role in training. They can:

● Include training on working with diverse and at-risk groups.

● Use sign language interpreters, either in person or remotely.

● Health services like check-ups, treatments, therapy, and counseling.

● PROVIDES AN OVERVIEW OF THE

Child Care System

It was found that psychological support more often was effective

Understanding the early traumatic stress reaction as a normative survival

Starting point for psychosocial recovery is to ensure the general

Hill and Hansen, in Man and Society in Disaster, stated “disasters

The goals for attaining and maintaining autonomy and

Two general approaches:

In the case of disaster human services, the empowerment takes place at

1. Disasters can disrupt the infrastructure by which communities meet community

As a modality of assistance to disaster survivors, DCM addresses three interconnected

Questions that should be addressed during predisaster planning include:

RESILIENCY IN THE FACE OF DISASTER

Vulnerable Populations (Sim and Cui, 2015):

● Women Differential Vulnerability: (Donner & Rodriguez,

Factors like poverty, mental health challenges, and exposure to

Disasters can pose a significant psychological risk to individuals with

In disaster response and mental health interventions, it's crucial to

1. Everyone who sees or experiences a disaster is affected by it in some way.

4. Acknowledging your feelings helps you recover.

5. Focusing on your strengths and abilities helps you heal.

6. Accepting help from community programs and resources is healthy.

7. Everyone has different needs and different ways of coping.

Mourning after a disaster is facilitated by rituals like funerals

A mental health coordinator is a crucial figure in disaster response

After a disaster, Psychological First Aid (PFA) is implemented to reduce

The Substance Abuse and Mental Health Services Administration

● Loss of a loved one in the event

Suicidal thoughts or plans—expressing indirect or direct thoughts of harming self.

● At least one re-experiencing symptom

Re-experiencing symptoms include:

● Wetting the bed after having learned to use the toilet

Mental health services continue long after a disaster, addressing persistent

2010 Haiti earthquake (Gamulin et al., 2012):

Hurricane Katrina (August 2005):

Global Warming Effects:

● Terrorism often targets noncombatants, including children, with incidents increasingly

Slone and Mann (2016) study:

Large-scale disasters can lead to catastrophic health emergencies, overwhelming local

Examples of how nurses can contribute to disaster preparedness in school

PIH used to be called

Pregnant women may

● First Stage (Can Last up to 20 Hours)

POSTTRAUMATIC STRESS DISORDER

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