DISASTER NURSING

DISASTER NURSINGDisaster definitions:

(Parker, 1984) a disaster is any patient generating incident that overloads either existing personnel, supplies, and equipment, or is any patient-generating incident in which backup supplies and personnel are not available in a reasonable amount of time.

(American Red Cross, 1975) an occurrence, either natural or man-made that causes human suffering and creates human needs that victims cannot alleviate without assistance.

1. Major Disaster defined as: any hurricane, tornado, storm, flood, high water, wind-driven water, tidal wave, earthquake, drought, fire, explosion, or other catastrophe in any part of the Philippines which, in the determination of the president, causes damage of sufficient severity and magnitude to warrant major disaster assistance above and beyond local/state emergency services by the government to supplement the effort and available resources of local governments and private relief organizations in alleviating the damage, loss, hardship, or suffering caused by a disaster.2. State of Emergency defined as: any of the various types of catastrophes included in the definition of a major disaster which requires Federal emergency assistance to supplement State and Local efforts to save lives and protect property, public health and safety, or to avert or lessen the threat of a disaster. Disaster Categories:1. Multiple patient incident the multiple patient incident occurs daily in EDs throughout the country.

An incident that generates at least two, but fewer than 10 patients. Is self-limiting and can usually be handled effectively without requiring aid from resources outside of the community.

Typical incidents that generate multiple patient incidents are MVA, fires, and public carrier incidents.

Most EDs have some type of plan for recalling additional personnel, if needed, in a limited situation.2. Multiple casualty incident generates at least 10 but fewer than 100 casualties and necessitates total community and

perhaps state involvement. Ex. Airplane crashes, snow storms, and floods.

The community-wide disaster plan must be established and functional to coordinate this type of situation.

3. Mass casualty incident generates more than 100 victims Additional aid and assistance is required.

Occur infrequently but still must be anticipated in any disaster planning activity.

Ex. Wars, major hurricanes, and earthquakes in which thousands of casualties may be generated on a continuing basis.

Types of Disasters:

1. External disasters- disasters which occurs outside the hospital. Can be labeled natural or man-made.a. Natural floods, tornadoes, blizzards, earthquakes, hurricanes, fire.

b. Man-made war, transportation accidents, fire, building collapse, food/water contamination.

2. Internal disasters- disasters which occur within an institution, such as hospital fire or bomb threat.

Epidemiology of a Disaster

1. Agent the physical items that actually causes the injury or destruction.

a. Primary agents falling building, heat, wind, rising water, and smoke.

b. Secondary agents bacteria and viruses that produces contamination or infection after the primary agent has caused injury and destruction.

2. Host humankind. Host factors include age, immunization status, preexisting health status, degree of mobility, and emotional stability.

3. Environment there are four factors that affect the outcome of a disaster.a. Physical Factors time when the disaster occurs, weather conditions, the availability of food and water, and the functioning of utilities such as electricity and telephone.

b. Chemical Factors leakage of stored chemicals into the air, soil, ground water, or food.

c. Biological factors those that occur or increase as result of contaminated water, improper waste disposal, insect or rodent proliferation, improper food storage.

d. Social factors those that contribute to the individuals social support system. Loss of family members, change in roles, and the questioning of religious beliefs.

Factors that influence response to disaster (Demi and Miles, 1983)

1. Situational Factors warning time before the disaster occurs, the nature and the severity of the disaster, physical proximity and closeness to the victims affected.

2. Personal Factors psychological proximity, coping ability, losses, role overload, and previous disaster experience.

Stages of a Disaster

Regardless of the origin, type or extent of a disaster, the stages are identical. Although the time involved in each stage will vary depending on the type of disaster, each situation will progress through the following stages:

1. Warning stage In every situation a warning period exist. The warning stage can extend from seconds to days. This stage may provide sufficient time for preparing to handle the potential event.

Important aspect in minimizing the loss of lives and mitigating damage.

It is during the warning phase that disaster plans are activated, emergency operations centers are established, and the affected area is evaluated or provided with in-place protection.Problems during the Warning Place:

1. Communication dissemination of vital information is a problem due to lack of time

2. Doubt the community must recognize the threat as legitimate and serious

3. Adaptation frequent false alarms are likely to jeopardize future responses to warnings

2. Impact stage The primary objective is staying alive. The impact phase can last anywhere from a few seconds or minutes (earthquake, plane crash, explosion) to a few days or weeks (floods, heat waves) to several months (droughts, epidemics).3. Inventory stage After the impact stage, survivors first assess the effects of the event and then identify what must be done next. It is essential that a preliminary damage assessment be conducted to determine emergency response priorities, needs, and limitations. This period of isolation is the interval in which immediate mitigative actions are required to prevent additional loss of life. 4. Rescue stage During the rescue stage, help arrives to rescue survivors and to help the injured. This begins when the first survivors render first aid to the victims, especially their own family members and continues through the arrival of the first local rescue organization, the establishment of a command post, and the convergence of other local and neighboring rescue organizations.

5. Remedy stage Recovery activities are initiated during the remedy stage. The remedy stage begins with the establishment of organized, professional, and voluntary relief operations. There is directed movement of the injured to the hospitals. Definitive actions aimed at preventing further injuries and damages are undertaken. This stage may last from days to weeks or even months before normal activities are resumed. 6. Recovery stage Encompasses total recovery from the impact and resulting situation. Holistic recovery and development of adaptive behavior required to produce lasting changes. Four Stages of the Victims emotional response:

1. Denial the victim may deny the magnitude of the problem or will understand the problem but seem unaffected emotionally.

2. Strong emotional Response the person is aware of the problem but regards the problem as overwhelming and unbearable. Reactions include sweating, speaking with difficulty, weeping, restlessness, sadness, anger, passivity. The may want to retell or relive the experience over and over.

3. Acceptance begins to accept the problems caused by the disaster and makes a concentrated effort to solve them. Feels more hopeful and confident.4. Recovery recovery from the crisis reaction. Victims feel they are back to normal and routines become important again. A sense of well-being is restored. The ability to make decision and carry out plans returns. Principles of disaster management: Garb and Eng (1969) identified 8 basic principles of disaster management

1. Prevent the occurrence of the disaster whenever possible.

2. Minimize the number of casualties if the disaster cannot be prevented.

3. Prevent further casualties from occurring after the initial impact of the disaster.4. Rescue the victims.

5. Provide first aid to the injured

6. Evacuate the injured to medical facilities

7. Provide definitive medical care

8. Promote reconstruction of lives

Common Problems at Mass Casualty Incidents Failure in adequate alerting

Lack of rapid primary stabilization of patients

Failure to move, collect, and organize patients rapidly at a suitable location

Use of overly time-consuming and inappropriate care methods

Premature commencement of transportation

Improper use of personnel in the field Lack of proper distribution of patients, which results in improper use of medical facilities

Lack of recognizable EMS command in the field

OVERVIEW OF THE TRIAGE PROCESS

Origin of triage A French term. Originated in the WWI battlefields. The term was applied to the process of sorting out casualties who could be returned to the front by concentrating the limited medical resources available on their ailments. The main intent was to treat those who would then be able to return to battle.

The triage technique has come to mean the process by which all injured individuals are sorted and classified according to the type and urgency of their condition. They are then transported under the assigned priorities for care.

Purpose of triage To deliver the greatest good to the greatest number.

Another type of triage has also come into being. In any given situation the decision must be made concerning the benefit vs. the risk, as well as injury vs. injury. These have to be considered for the well-being of the personnel as well as the victim or the personnel may very well become the victim.

The nurses patient care skills are desperately needed in the disaster situation. Before nurses can be effective at the scene or at the facility they must understand the challenges that can distract from their efforts (e.g. hazardous environment, overwhelmed system, inappropriate patient care)

POINTS TO REMEMBER ABOUT TRAIGE/ CONSIDERATIONS:

A. Identification of the patient Marking patient with tags to help the disaster personnel know the status of each victim and their prioritization.

B. Assessment Implies the exercise of judgment. This means the observation and evaluation of significant changes in a clients physical condition or the determination of the relative significance of a clients verbal complaints. The triage agent should act in accordance with accepted standards. C. Facilitation of treatment In performing triage, the nurse or EMT will determine the order in which clients are treated. In situations where there is doubt whether an emergency exists, the doubt will be construed in favor of the client.

D. Communication Professional assessment implies that something meaningful will be done once the assessment is made. Communication, which includes documentation, is an integral part of assessment, at least from the legal standpoint. Effective communication must take place between the triage personnel and other personnel. The triage notes should be a permanent part of the clients emergency department record.

E. Legal liability Increased professional responsibility carries with it increased accountability and liability. Basic legal precepts offer 3 guidelines for action:1. Personal responsibility for ones own acts

2. Reasonable care under the circumstances

3. Care in accordance with accepted standards

PERSONNEL IN THE TRIAGE SYSTEM

A. Emergency squad personnel fire, rescue, first respondents, EMTs, paramedics, divers, etc. the EMT is the most qualified and best triage officer.

B. Nursing personnel- RNs, LPNs, nursing aids, techs, ward clerks

C. Physician staff- all different specialties may be available

D. Hospital administration- safety officers, maintenance, accountants, secretaryAREAS OF TRIAGE

A. Disaster Scene

Simple triage is usually used in a scene of mass casualty, in order to sort patients into those who need critical attention and immediate transport to the hospital and those with less serious injuries. In the scene of mass casualty or at the scene of a disaster, triage is done to prioritize patients based on the severity of their condition so as to treat as many as possible when resources are insufficient for all to be treated immediately.CATEGORIES OF SEVERITY/ PRIORITIZATION

Class I. (critical top priority) Red Tag Acute respiratory distress Airway obstruction

Shock

Massive hemorrhage

Rx. ABCs of resuscitation, Prioritize for transport

Class II. (severe urgent care priority) Yellow Tag If untreated within 1 - 2 hrs. permanent disability or death

Penetrating or open abdominal wounds

Major burns

Closed head injuries with decreased LOC

Rx. ABCs of resuscitation, Prioritize for transport

Class III. (non-urgent delayed priority) Green Tag Care within 2 -6 hrs.

Moderate burns

Fractures or dislocations

Eye injuries

Lacerations, facial injuries without airway obstruction

Sprains and strains Contusions

Rx. ABCs of resuscitation, Prioritize for transport

Class IV. (morgue at disaster site until bodies can be moved) Black Tag

The victims are continually assessed at the disaster triage site. Their status may change and need to be upgraded to a higher priority or to a class IV. The victims will be assessed when in transport also, and be reclassified en route to the hospital. Triage will also be done at the hospital according to that facilitys plan.

4 STEPS IN TRAUMA VICTIM MANAGEMENT

1. Primary survey - (find all immediate threats to life)

a. Evaluate airway (c-spine control and initial LOC evaluation)

b. Evaluate breathing

c. Evaluate circulation (bleeding and control major bleeding)

d. Evaluate disability (mini neuro check, apply cervical collar)

e. Evaluate exposure remove clothing

Primary survey should not take more than 1.5 2 minutes.

2. Transport decision and Critical InterventionCritical trauma transported. All Rx. done in transport

Intervention to be done at scene:

Removal of airway obstruction Stop major bleeding Seal sucking wounds Hyperventilate Decompression of tension pneumothorax 3. Secondary survey (under 5 minutes) Critical patients Done during transport:

Vital signs History of patient and trauma event Head to toe exam including neuro Bandaging and splinting Continual monitoringIf secondary survey reveals any of the following, transport immediately

Tender distended abdomen Pelvic instability Bilateral femur fracturesBrief neuro exam:

a. LOCA alert

V responds to verbal stimuli

P responds to pain

U unresponsive

b. Motor can toes be movedc. Sensation can feel touch to digitsd. Pupils PERLCritical injuries can be simplified into 3 conditions based on s/s

1. Difficulty with respiration2. Difficulty with circulation3. Decreased LOCB. HOSPITALAs the patients enter the emergency department, triage team staff should be stationed at the ambulance bay. As the patient arrives, the triage team does a rapid triage evaluation, while a clerk applies a stat record identification band, hands the corresponding triage slip to the triage officer, places the stat chart on the gurney with the patient, and logs the stat medical record number, stat name number, and, if possible, the patient name and emergency department area assignment. As a patient is stabilized and leaves the emergency department, the disposition is entered on the tracking log. After rapid assessment, the patient is triaged to a treatment location and team, in the emergency department (or other designated area in the facility), where a more thorough evaluation and assessment will take place.