Disaster Nursing

by: Liza Grace Colasito Dann Louie Praxides

Disaster Nursing
Definition: Disaster is defined as any occurrence that causes damage , economic disruption ,loss of human life deterioration in health and health services on a scale sufficient warrant and extraordinary response from outside the affected community or area. Disaster is the occurrence of a sudden or major WHO which disrupts the basic fabric and normal functioning of a society . TYPES OF DISASTER : There are two types of disasters one is natural and other is manmade . In both these two types many categories of disasters occur which will be discussed in detail later. Every catastrophic events has its own special features. Some events are predicted but some occur without warning

Disaster Nursing
Warfare and terrorism are just two of the reasons that health care providers need to plan for mass casualties. Air plane crashes, train crashes, toxic substance spills, and infectious disease outbreaks are other disasters that can result in casualties and tax the resources of health care facilities and communities. In addition, natural phenomena such as floods, tornadoes, hurricanes, fires and earthquakes, kill and injure hundreds of thousands of people worldwide each year.

Federal, State, and Local Responses to Emergencies.

Many resources are available at the federal, state, and local level to assist in the management of mass casualty incidents (MCI), disasters and emergencies. MCI defined as any incident that results in more patients than daily resources can handle. Local communities must be prepared to act in isolation and provide competent care up to 5 days before federal or the other resources become available.

Disaster Levels
Disasters are often categorized by level to indicate the anticipated level of response. Level I: Local emergency response personnel and organizations can contain and effectively manage the disaster and its aftermath. Level II: Regional efforts and aid from surrounding communities are sufficient to manage the effects of the disaster. Level III: Local and regional assets are overwhelmed; statewide or federal assistance is required.

Federal Agencies
State authorities must request federal assistance with sources through appropriate government channels. A request for federal resources generally is made when local resources have become or are expected to become depleted. >DHHS (Dept. of Health and Human Svc.) >DOJ >DOD (Dept. of Defense) >DHS (Dept. of Homeland Security)

DHS Threat Levels

Red (severe, usually site is specified) Orange (High risk of attack but a specific site may not yet identified) Yellow (elevated, possible risk but no defined site)

Blue (guarded, general risk but no specific risks identified)

Green (low, little or no risk perceived or known)

State and Local Agencies

State and local agencies are first one to combat disaster, some of this agencies are Philippine National Red Cross, Poison Control Centers and other local volunteer organizations.

Hospital Emergency Preparedness Plans

Health care facilities are required by the Joint Commission to create a plan for emergency preparedness and to practice this plan at least twice a year. Before the basic emergency operations plan (EOP) can be developed, the planning committee of the health care facility first evaluated characteristics of the community to identify the likely types of natural and man-made disasters that might occur.

TRIAGE
Triage is the sorting of patients to determine the priority of their health care needs and the proper site for treatment. In NON-DISASTER situations, health care team assign a high priority and allocate the most resources to those who are the most critically ill, however in a DISASTER, when health care providers are faced with a large number of casualties, the fundamental principle guiding resource allocation is to do the greatest good for the greatest number of people. Decision are based on the percentage of survival although it really contradict our ethical principle.

TRIAGE
Staff should control all entrances to the acute care facility so that incoming patients are directed to the triage area first. Triage area may be outside the entry or just at the door of the ED. This facilitates the triage of all patients, including those arriving by medical transport and those who walk into the ED.

Triage categories during a mass casualty incident.

1. Immediate (1) (Red) -injuries are life threatening but survivable with minimal intervention. -ex: airway obstruction secondary to mechanical cause, shock, hemothorax, open fractures of long bones. 2. Delayed (2) (Yellow) -injuries are significant and require medical care, but can wait hours without threat to life or limb. Individuals in this group receive tx only after immediate casualties are treated. -ex: maxillofacial wounds without airway compromise, debridement, and external fixation.

3. Minimal (3) (Green) -injuries are minor and treatment can be delayed hours to days. Individuals in this group should be moved away from the main triage area. -ex: Upper extremity fractures, minor burns, sprains, small lacerations without significant bleeding. 4. Expectant (4) (Black) -injuries are extensive and chances of survival are unlikely even with definitive care. Persons in this group should be separated from other casualties, but not abandoned. Comfort measures should be provided when possible. -ex: unresponsive patients with penetrating head wounds, high spinal cord injuries, wounds involving multiple anatomical sites and organs, no pulse no blood pressure, pupils fixed and dilated.

The Nurses Role in Disaster Response Plans

The role of nurse during a disaster varies. Nurses may be asked to perform duties outside their areas of expertise and may take on responsibilities normally held by physicians or advanced practice nurses. For example, a critical care nurse may intubate a patient or even insert a chest tube. A nurse may perform wound debridement or suturing, and serve as a triage officer. Remember: Nurses should remember that nursing care in a disaster focuses on essential care from a perspective of what is best for all patients.

Considering Ethical Conflicts

Disaster can present a disparity between the resources of health care agency and the needs of the victims. This generated ethical dilemmas for nurses and other health care providers. Issues include conflicts related to the following: - Rationing Care - Futile Therapy - Consent - Duty - Confidentiality - Resuscitation - Assisted Suicide

Managing Behavioral Issues

Depression Anxiety Somatization Post traumatic stress disorder Substance abuse Interpersonal conflicts Impaired performance

Natural Disaster
Natural Disaster may result in mass casualties. Natural disasters can occur anywhere at any time and include events such as tornadoes, hurricanes, floods , avalanches, tidal waves, earth quakes and volcanic eruptions. The majority of clients arrives just a hour after the event. Casualties arrive at hospitals in three ways:

1st wave: consists of minimally injured people who arrive at their own accord.

2nd wave: consists of severely injured patients.

3rd wave: consists of injured patients who arrive after they are discovered by rescuers:

WEAPONS OF TERROR
Blast Injury Types of explosive devices: Pipe bombs, Molotov cocktails, fertilizer bombs, and dirty bombs (so called because they spread radiation) a. Physical Injuries the actual blast occurs during the initial seconds of the bombing causes a pressure wave or primary blast wave. Injuries can result from the impact of the explosion, the primary blast wave, or shrapnel within the bomb. b. Blast Lung results form the vlast wave as it passes through air filled lungs. The result is hemorrhage and tearing of the lung. Typical s/sx: dyspnea, tachypnea, or apnea (depending on the severity) c. Tympanic Membrane Rupture the most frequent injury after subjection to a pressure wave because it is the bodys most sensitive organ to pressure d. Abdominal and Head Injuries blast abdomen may be evidenced by abdominal hemorrhage and internal organ injury. The typical s/sx: pain, guarding, rebound tenderness, rectal bleeding and nausea and vomiting. e. Special Population too old, bone fracture.

WEAPONS OF TERROR
Biologic Weapons are weapons that spread disease among the general population or the military. Biologic Warfare is a cover method of effecting terrorist objectives. The potential use of biological agents calls for continous increased index of suspicion by clinicians.

Examples of potential bioweapons agents

Anthrax: Perhaps the best known biological weapon is anthrax, the Bacillus anthracis bacterium. Research to weaponize anthrax was performed by the UK during World War II. The UK produced million of cattle cakes spiked with anthrax to retaliate in case the Nazis would have used biological weapons. After field trials with anthrax bombs on Gruinard Island in Scotland, this isle was lethally contaminated and off limits for any human being for nearly 50 years. Tularemia is another first choice biological weapon agent, as it is like anthrax relatively stable in the environment and can be delivered through airborne particles (aerosols). Plague, caused by the bacterium Yersinia pestis, was one of the first infectious diseases that have been used for military purposes. In 1346, after three years of blockading the city of Kaffa, the Tartars catapulted their plague-victims into the city, causing a deadly epidemic within weeks.

Examples of potential bioweapons agents

Smallpox has been globally eradicated in 1977. However, smallpox virus (called Variola) is still kept in research institutions. Biowarfare with smallpox goes back to the 18th century, when the British sold horse blankets contaminated with smallpox to Native Americans in the USA. The former USSR is alleged to have produced weaponized smallpox virus in a facility called Vector near Novosibirsk. As smallpox vaccinations were stopped some 20 years ago, especially the youth is extremely vulnerable to smallpox today.

Ebola, one of the most deadly viruses, is a potential bioweapon. The Japanes Aum sect, known for the poisonous gas attack on the Tokyo Metro, allegedly attempted to get hold of Ebola samples by sending cult members to Zaire during an Ebola outbreak.

Foot and mouth disease is an example for anti-animal weapons. Biological weapons are not restricted to human pathogens. Any living agent that is used for hostile purposes regardless of its origin and target is considered a biological weapon under the BTWC.

Examples of potential bioweapons agents

Also anti-crop bioweapons have been developed. For example, the USA had an arsenal of 900kg of a rice pathogen during the Vietnam war, before the US biowarfare program was dismantled in the late 1960s. Toxins are also covered by the Biological and Toxin Weapons Convention. Toxins are highly lethal substances that are usually produced by living organisms, such as fungi, algae or bacteria. One of most deadly toxins known to humankind is botulinum toxin, which has been weaponized in the past in offensive biological weapons programs.

Chemical Weapons
Agents that may be used in chemical warfare or for terrorist purposes are overt agents in that the effects are more apparent and occur more quickly than those caused by biologic weapons. Types of chemicals: 1. Vesicants (Lewisite, Sulfur Mustard, Nitrogen Mustard, Phosgene) - are chemicals that cause blisstering and result in burning, conjunctivitis, bronchitis, pneumonia, hematopoietric suppresion, and death. It was used in World War I and in the Iran-Iraq conflict.

Treatment: -decontamination using soap and water. -scrubbing using hypochlorite solutions should be avoided because they increase penetration. -for respiratory exposure, intubation and bronchoscopy to remove necrotic tissue are essential.

Chemical Weapons/Types of chemicals

2. Nerve Agents (Sarin, Soman organophosphates) - inexpensive, effective in small quantities and easily dispersed. In the liquid form, nerve agents evaporate into a colorless, odorless vapor. Nerve agents can be inhaled or absorbed percutaneously or subcutaneously. - a small amount of nerve agent is enough ti result in sweating and twitching at the site of exposure. A larger amount results in more systemic symptoms. Effects can begin anywhere from 30 minutes up to 18 hours after exposure. Added clinical manifestations are cholinergic crisis, nausea and vomiting, diarrhea and weakness.

Treatment: - Decontamination with copious amounts of soap and water or saline solution for 8-20 minutes is essential. - The water is blotted off the skin, not wiped off. - Suctioning can perform when patient is having dob. - Atropine sulfate and Pralidoxime (Protopam) administration to return anticholinergic activity (decreased secretions, tachycardia, and decreased gastrointestinal motility)

Chemical Weapons/Types of chemicals

3. Blood Agents (Cyanide) such as hydrogen cyanide and cyanogen chloride have a direct effect on cellular metabolism, resulting in asphyxiation through alterations in hemoglobin. -cyanide can be ingested, inhaled, or absorbed through the skin and mucous membranes. Cyanide is protein bound and inhibits aerobic metabolism, leading to respiratory muscle failure, respiratory arrest, cardiac arrest and death.

Treatment: -rapid administration of amyl nitrate, sodium nitrate and sodium thiosulfate. (first patient is intubated and placed on a ventilator, next amyl nitrate pearls are crushed and placed in the ventilator reservoir to induce methemoglobinemia.

Chemical Weapons/Types of chemicals

4. Pulmonary Agents (Phosgene and Chlorine) -destroy the pulmonary membrane that separates the alveolus from the capillary bed, disrupting alveolar-capillary oxygen transport mechanisms. -s/sx accompanied with this are: pulmonary edema with shortness of breath, cough followed by frothy sputum production. - A particulate air-filter mask is the only protection required to protect health care personnel.