SEMINAR ON DISASTER NURSING

SUBMITTED TO SUBMITTED BY Mrs .SUJAMOL SCARIA Ms .RESHMI E.R PROFESSOR Mr. SHINE GEORGEGOVT .COLLEGE OF NURSING 1ST BATCH Msc( N)THRISSUR

GOVT .COLLEGE OF NURSING THRISSUR

DISASTER NURSING

INTRODUCTION The need for professional nurses to be prepared in emergency and disaster nursing is increasingly evident as the complexity of our lives increases owing to the discovery of new scientific knowledge and its application to the everyday world. Because nurses represent the largest group of trained professional health workers available, their awareness and of preparation for emergency care of the ill and injured are essential.

Such independent nursing function as observation, maintenance of personal health measures, health teaching, prevention of illness, control of the environment and supervision and direction of either professional or nonprofessional nursing personnel are already recognized activities as preparation for providing care in emergency situations. On the other hand, the administration of medications and treatments, while dependent on others from physicians, is continually being evaluated and more responsibility for it is being shifted to professional nurses.

Professional nurses, then, need to be prepared to meet everyday emergencies in terms of first-aid and lifesaving measures. They also need to be prepared to meet emergencies as they occur on ward nursing units in hospitals and as emergency cases are brought to hospital facilities. An awareness of the most common emergency cases and their management as found in specific localities is a professional responsibility nurses must assume.

Nurse’s functions are expanded further in the case of mass disasters either resulting from natural phenomena or man-made including enemy attack. As the scope of disaster increases, nurses shift their emphasis of participation from direct, personalized care to patients to the direction, teaching and supervision of non professional personnel. The professional role is further expanded in usefulness when the nurse assumes responsibility to be knowledgeable in citizenship.

DEFINITIONS

1. “A disaster can be defined as any occurrence that cause damage, ecological disruption, loss of human life, deterioration of health and health services, Vs a scale sufficient to warrant as extraordinary response from outside the affected community or area.” (W.H.O.)

2. “An occurrence of a severity and magnitude that normally results in death, injuries and property damage that cannot be managed through the routine procedure and resources of government.” (FEMA - Federal Emergency Management Agency)

3. “A disaster can be defined as an occurrence either nature or man made that causes human suffering and creates human needs that victims cannot alleviate without assistance.”(ARC-American Red Cross)

4.United Nations defines “disaster is the occurrence of a sudden or major misfortune which disrupts the basic fabric and normal functioning of a society or community.” The Disaster Relief Act of 1974 defines a major disaster as "any hurricane, tornado, storm, flood, wind-

driven water, tidal wave, earth- quake, volcanic eruption, landslide, mudslide, snowstorm, drought, fire, explosion, or other catastrophe in any part of the United States [that], in the determination of the President causes damage of sufficient severity and magnitude to warrant major disaster assistance above and beyond emergency services by the Federal Government to supplement the efforts and available resources of the State and Local Governments, and private relief organizations in alleviating the damages, loss, hardship, and suffering caused by the disaster" (Federal Emergency Management Agency [FEMA], Washington).

A hazard can be defined as any phenomenon that has the potential to cause disruption or damage to people and their environment. Disasters are not confined to a particular part of the world, they can occur anywhere and at any time. Emergencies and disaster do not only affect health and well being of people, large number of people are displaced, injured, killed or subjected to greater risk of epidemics. Considerable economic harm is also common. Disasters cause greater harm to existing infrastructure and threaten the future of sustainable development. Extensive damage to property, roadways, electrical lines, and other crucial infrastructures limits a region’s ability to respond. Whether the origin of the disaster is natural or attributable to human causes, the outcomes can be devastating. These events often leave the local first responders, medical systems, and governmental operations overwhelmed.

A major disaster can create a mass casualty incident or a multiple casualty incident. A multiple casualty incident is one in which there are more than two but fewer than 100 persons injured. Multiple casualties generally strain and, in some situations, might overwhelm the available emergency medical services and resources. A mass casualty incident is a situation with a large number of casualties, usually 100 or more, that significantly overwhelms available emergency medical services, facilities, and resources.

Disaster management is defined as "the managerial function charged with creating the framework within which communities reduce vulnerability to hazards and cope with disasters." ( Federal Emergency Management (FEMA)). Disaster management includes the development of disaster recovery plans, for minimizing the risk of disasters and for handling them when they do occur, and the implementation of such plans.

Disaster nursing can be defined as “the adaptation of professional nursing knowledge, skills and attitude in recognizing and meeting the nursing, health and emotional needs of disaster victims.

“Disaster Nursing is nursing available”practiced in a situation where professional supplies, equipment, physical facilities and utilities are limited or not

‘DISASTER’ alphabetically means

D - DestructionsI - IncidentsS - SufferingsA - Administrative, Financial Failures

S - Sentiments T - Tragedies E - Eruption of Communicable diseases R - Research programme and its implementation

"   Emergency Nursing is a specialty in which nurses care for patients in the emergency or critical phase of their illness or injury and are adept at discerning life-threatening problems, prioritizing the urgency of care, rapidly and effectively carrying out resuscitative measures and other treatment, acting with a high degree of autonomy and ability to initiate needed measures without outside direction, educating the patient and his family with the information and emotional support needed to preserve themselves as they cope with a new reality.”

Types of Disasters Types

Category 1- Water and Climate related disasters

a) Floodb) Droughtc) Costal erosiond) Thunder and Lighteninge) Cyclone and Storms etc.

Category 2 - Geologically related Disasters a) Landslides and Mudflowsb) Earthquakesc) Dam failuresd) Tsunamie) Dam bursts etc.

Category 3 - Chemical Industrial and Nuclear related disastersa) Leakage of hazardous materials at the time of their manufacture, processing and

transportation.b) Disasters due to manufacture, storage, use and transportation of products, pesticides

etc and waster produced during the manufacturing process etc.Category 4 - Biological related disasters

a) Epidemicsb) Cattle epidemicsc) Food poisoningd) Pest attacks etc.

Category 5- Man-made disastersa) Forest fireb) Urban firec) Village fired) Festival related disasterse) Road, Rail and Air Accidentsf) Boat capsizingg) Oil spill

h) Major building collapsei) Serial Bomb blastj) Illicit Liquor Tragedyk) Drug abusel) Drowningm) Tanker lorry mishapsn) Pollution (water, air and soil)o) Family suicidesp) Environmental disastersq) Communal riotsr) Stamped etc.

Essentially, there are two types of disasters: natural and man- made. Both types vary

in intensity, severity, and impact. Natural disasters include hurricanes, tornadoes, flash

floods, blizzards, slow-rising floods, typhoons, earthquakes, avalanches, epidemics, and

volcanic eruptions. Man-made disasters include war, chemical and biological terrorism,

transportation accidents, food or water contamination, and building collapse. Fire can be

either man-made or naturally occurring.

Epidemiology

Epidemiology is the study of pattern of disease occurrence in human populations and the factors that influence these patterns. Disaster may be studied and analyzed using the epidemiological frame work of agent, host and environment in an attempt to predict, prevent, or control the outcomes of a disaster. As stated earlier there are two types of disasters: natural and man-made. Both types will vary in intensity, severity and impact.

Disaster Agent: To apply the epidemiological framework in a disaster situation, the agent is the physical item that actually causes the injury or destruction. Primary agents include falling buildings, heat, wind, rising water and smoke. Secondary agents include bacterial and viruses that produce contamination or infection after the primary agent has caused injury or destruction.

Primary and secondary agents will vary according to the type of disaster. For example, a hurricane with rising water can cause flooding and high winds; these are primary agents. The secondary agents would include damaged buildings and bacteria or viruses that thrive as a result of the disaster. In an epidemic, the bacteria or virus causing a disease is the primary a disease is the primary agent rather than the secondary agent.

Host: In the epidemiological frame work as applied to disaster, the host is human kind. Host factors are those characteristics of humans that influence the severity of the disaster’s effect. Host factors include age, immunization status, pre-existing health status, degree of mobility and emotional stability. Individuals most severely affected by a disaster are elderly persons, who may have trouble leaving the area quickly; young children whose

immune systems are not fully developed and persons with respiratory or cardiac problems. For example, a fire in a nursing home is potentially more lethal than a fire in a college dormitory. In a fire situation elderly individuals in the nursing home are at greater risk because they are less physically fire and more susceptible to smoke and other consequences than are young college students.

Environment: Environmental factors that affect the outcome of a disaster include physical, chemical, biological and social factors. Physical factors include the time when the disaster occurs, weather conditions, the availability of food and water and functioning of utilities such as electricity and telephone service. Chemical factors influencing disaster outcome include leakage of stored chemicals into the air, soil, ground water or food supplies. Biological factors are those that occur or increase as a result of contaminated water, improper food storage, or lack of or rodent proliferation owing to interrupted electrical services. Social factors are those that contribute to the individual’s social support systems. Loss of family members, changes in roles, and the questioning of religious beliefs are social factors to be examined after a disaster.

Factors affecting Disaster

Host factorsIn the epidemiological frame work as applied to disaster the host is a human-kind.

Host factors are those characteristics of humans that influence the severity of the disaster effect. Host factors include

Age Immunization status Degree of mobility Emotional stability

Environmental factors:This includes:

1. Physical factors Whether conditions, the availability of food, time when the disaster occurs, the

availability of water and the functioning of utilities such as electricity and telephone service. 2. Chemical Factors

Influencing disaster outcome include leakage of stored chemicals into the air, soil, ground water or food supplies.

Eg: Bhopal Gas Tragedy3. Biological Factors

Are those that occur or increase as result of contaminated water, improper waste disposal, insect or rodent proliferations improper food storage or lack of refrigeration due to interrupted electrical services.

Bioterrorism: Release of viruses, bacteria or other agents cause illness or death.

4. Social Factors Are those that contribute to the individual social support systems. Loss of family

members, changes in roles and the questioning of religious beliefs are social factors to be examined after a disaster.

5. Psychological Factors . Psychological factors are closely related to agents, host and environmental

conditions. The nature and severity of the disaster affect the psychological distress experienced by the victims

PHASES OF A DISASTER

There are three phases of disaster. 1.      Pre-Impact Phase2.      Impact Phase 3.      Post – Impact Phase

PRE-IMPACT PHASE

It is the initial phase of disaster, prior to the actual occurrence. A warning is given at the sign of the first possible danger to a community with the aid of weather networks and satellite many meteorological disasters can be predicted. The earliest possible warning is crucial in preventing toss of life and minimizing damage. This is the period when the emergency preparedness plan is put into effect emergency centers are opened by the local civil, detention authority. Communication is a very important factor during this phase; disaster personnel will call on amateur radio operators, radio and television stations.The role of the nurse during this warning phase is to assist in preparing shelters and emergency aid stations and establishing contact with other emergency service group.

IMPACT PHASE

The impact phase occurs when the disaster actually happens. It is a time of enduring hardship or injury end of trying to survive. The impact phase may last for several minutes (e.g. after an earthquake, plane crash or explosion.) or for days or weeks (eg in a flood, famine or epidemic). The impact phase continues until the threat of further destruction has passed and emergency plan is in effect. This is the time when the emergency operation center is established and put in operation. It serves as the center for communication and other government agencies of health disseminates healthcare providers to staff shelters. Every shelter has a nurse as a member of disaster action team. The nurse is responsible for psychological support to victims in the shelter.

POST – IMPACT PHASERecovery begins during the emergency phase and ends with the return of normal community order and functioning. For persons in the impact area this phase may last a lifetime (e.g. – victims of the atomic bomb of Hiroshima). The victims of disaster in go through four stages of emotional response.

1. Denial - during the stage the victims may deny the magnitude of the problem or have not fully registered. The victims may appear usually unconcerned.

2. Strong Emotional Response – in the second stage, the person is aware of the problem but regards it as overwhelming and unbearable. Common reaction during this stage is trembling, tightening of muscles, speaking with the difficulty, weeping heightened, sensitivity, restlessness sadness, anger and passivity. The victim may want to retell or relieve the disaster experience over and over.

3. Acceptance - During the third stage, the victim begins to accept the problems caused by the disaster and makes a concentrated effect to solve them. It is important for victims to take specific action to help themselves and their families.

4.      Recovery - The fourth stage represent a recovery from the crisis reaction. Victims feel that they are back to normal. A sense of well-being is restored. Victims develop the realistic memory of the experience.

EFFECTS OF DISASTER ON THE COMMUNITY

1. Injuries2. Emotional stress3. Epidemic diseases4. Increase in indigenous diseases5. Scarcity of food, water, electricity and communication facilities6. Population mobility/ displacement

7. Local and regional economies can be negatively affected

In a disaster, the social and psychological reactions of individuals are closely interwoven with those of the community. According to the ARC (1987), the four phases of a community's reaction to a disaster are as follows:

¶ Heroic phase: Strong, direct emotions focusing on helping people to survive and recover

¶ Honeymoon phase: A drawing together of people who simultaneously experienced the catastrophic event

¶ Disillusionment phase: Feelings of disappointment because of delays or failures when promises of aid are not fulfilled (people seek help to solve their own personal problems rather than community problems)

¶ Reconstruction phase: A reaffirmation of belief in the community when new buildings are constructed (delays in this phase might cause intense emotional response)

AGENTS OF HARM OR DAMAGE IN A DISASTER

The agent is the physical item that actually causes the injury or destruction. Primary agents include falling buildings, heat, wind, rising water, chemical and biological agents, and smoke. Secondary agents include bacteria and viruses that produce contamination or infection after the primary agent has caused injury or destruction.Primary and secondary agents vary according to the type of disaster. For example, a hurricane with rising water can cause flooding and high winds; these are primary agents. Secondary agents include damaged buildings' infrastructure and bacteria or viruses that thrive as a result of the disaster. In an epidemic, the bacteria or virus causing a disease is the primary agent rather than the secondary agent.

FACTORS AFFECTING SCOPE AND SEVERITY OF DISASTERS

A number of issues affect the degree that impact disasters will have on individuals, families, and communities. These factors are addressed in the following section.

Vulnerability of a Population or Individual

Certain characteristics of humans influence the severity of the disaster's effect on individuals and communities. For example, the age of a person, pre-existing health problems, degree of mobility, and emotional stability all play a part in how someone responds in a disaster situation. Those most severely affected by a disaster are the physically handicapped, who have limited mobility or are wheelchair dependent; people who are ventilator dependent or attached to other life-support equip-ment; the mentally challenged; elderly persons, who might have trouble leaving the area quickly; young children whose immune systems are not fully developed; and persons with respiratory or cardiac problems.

Environmental Factors and Type of Impact

In a disaster situation, physical, chemical, biological, and social factors influence the scope and severity of the outcomes. Physical factors include the time when the disaster occurs, weather conditions, the availability of food and water, and the functioning of utilities, such as electricity and telephone service.

Leaks of stored chemicals into the air, soil, ground water, or food supplies are examples of chem-ical factors. Biological factors are those that occur or increase as a result of contaminated water, improper waste disposal, insect or rodent proliferation, improper food storage, or lack of refrigeration owing to interrupted electrical services. Some social factors to consider are those related to an individual's support systems. Loss of family members, changes in roles, and the questioning of religious beliefs are social factors to be examined after a disaster. In general, individuals and families with ample social support do better coping with emergencies than individuals with little or no social support.

Warn ing T ime and Prox imi t y t o D i sas t e r

Demi and Miles (1983) have identified both situational and personal factors that influence an individual's response to a disaster. Situational variables include the amount of warning time before disaster occurs, the nature and the severity of the disaster, physical proximity to the disaster, and the availability of emergency response systems. An individual's reaction to a disaster will be greater if there is little or no warning, and the victim is in close physical proximity to the disaster site. For example, the loss of life in tornadoes is often affected by warning systems. Where towns have warning sirens and a planned system monitoring for potential tornadoes, more people are able to take shelter. In these instances, even with substantial damage to buildings and personal property, personal injuries, and deaths are limited.

The closer an individual is to the actual site of the disaster and the longer the individual is exposed to the immediate site of the disaster, the greater the psychological distress that the individual experiences.

Ind i v idua l Percep t i on And Response

Personal variables influence an individual's reaction to a disaster. Psychological proximity, coping ability, personal losses, role overload, and previous disaster experience all influence individual response. An individual's risk for developing severe psychological consequences is greater if that person is emotionally close to the individuals affected, has compromised coping abilities, has experienced many losses, feels overloaded in her or his role, or has never before experienced a dis-aster. An individual who perceives a disaster to be less severe than it is, will probably have a less severe psychological reaction than a person who perceives the situation as catastrophic (Richtsmeir & Miller, 1985). An individual's perception of an emergency or disaster might evolve over time as the person begins to acknowledge the full impact of the disaster. The human mind is capable of allowing perceptions to be only as disastrous as the mind can cope with at a given time.

DIMENSIONS OF A DISASTER

Disasters have a number of dimensions in which they can differ: predictability, frequency, controllability, time, and scope or intensity. These dimensions influence the nature and possibility of preparation planning, as well as response to the actual event.

Predictability

Some events are more easily predictable than others. Advances in meteorology have made it more feasible to accurately predict the probability of certain types of natural, weather-related disasters (e.g., tornadoes, floods, and hurricanes), whereas other disasters, such as earthquakes, are not as easily predictable. Man-made disasters, such as explosions or vehicle crashes, are also less predictable. Whenever an event is predictable, authorities and emergency personnel have more time to prepare for the situation than when an event is not foreseeable.

Frequency

Although natural disasters are infrequent, they appear more often in certain geographic locations. Residents of the Gulf Coast of the United States live in what is commonly referred to as "hurricane alley." People who live near large river systems are at g r ea t e r r i s k for flooding than p eop l e who live e l s ewhere . How ever, the greater frequency of natural disasters might or m igh t not prepare citizens for their occurrence. Some citizens b e come immune to repeated warnings and are less likely to seek shelter to protect themselves and their property when warned. Other citizens take each warning seriously and regularly take appropriate safety precautions.

Controllability

Some situations allow pre-warning and control measures that can reduce the impact of the disaster; others do not. Mitigation is a term that is used in disaster planning that describes actions and/or processes that can be used to prevent or reduce the damage caused by a specific disaster event. Emergency planners were able to control some of the effects of the flooding by sandbagging levees and river banks to reduce the effects of water damage and by deliberately blasting dikes and dams to divert flood waters to less populated areas. The immediate impact on people was reduced by the ability of emergency personnel to organize evacuations and reduce the risk of injury and death.

Mitigating measures can be implemented well in advance of potential disasters. The enactment of building standards and codes intended to reduce the harmful effects of a disaster are one example. More stringent fire safety measures (e.g., smoke detectors, sprinkler systems, improved fire doors) have made more newly constructed buildings safer in the event of an actual fire.

Scope and Intensity

Scope refers to the geographic area and social space dimension impacted by the disaster agent. A disaster might be concentrated in a very small area or involve a very large geographic region. A disastrous event might affect a small segment or a large percentage of the population in a geo-graphic area. I n t ens i t y refers to a disaster agent's ability to inflict damage and injury. A disaster can be very intense and highly destructive, causing many injuries, deaths, and property damage, or less intense, with relatively little damage done to property or individuals.

Scope and intensity should be considered separately for disaster planning. For example, in the scenario of a building explosion, the scope is small; affecting a limited area of a community, but the intensity is great. The explosive forces are highly destructive to the building and cause death and injury to people within the building and in the immediate vicinity. An explosion at a water-purifying plant might cause minimal injury to property and personnel at the plant, but might reduce or eliminate the water supply for an entire community for days or even weeks.

PRINCIPLES OF DISASTER MANAGEMENT

According to Garb and Eng (1969), there are eight fundamental principles that should be followed by all who have a responsibility for helping the victims of a disaster. It is critical that rescue workers use these principles in proper sequence, or they will be ineffective and possibly detrimental to disaster victims. The eight basic principles are as follows:

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.

In 2007, Dr. Wayne Blanchard of FEMA’s Emergency Management Higher Education Project, at the direction of Dr. Cortez Lawrence, Superintendent of FEMA’s Emergency Management Institute, convened a working group of emergency management practitioners and academics to consider principles of emergency management. The group agreed on eight principles that will be used to guide the development of a doctrine of emergency management. According to them, Emergency management must be:

Comprehensive – emergency managers consider and take into account all hazards, all phases, all stakeholders and all impacts relevant to disasters.

Progressive – emergency managers anticipate future disasters and take preventive and preparatory measures to build disaster-resistant and disaster-resilient communities.

Risk-driven – emergency managers use sound risk management principles (hazard identification, risk analysis, and impact analysis) in assigning priorities and resources.

Integrated – emergency managers ensure unity of effort among all levels of government and all elements of a community.

Collaborative – emergency managers create and sustain broad and sincere relationships among individuals and organizations to encourage trust, advocate a team atmosphere, build consensus, and facilitate communication.

Coordinated – emergency managers synchronize the activities of all relevant stakeholders to achieve a common purpose.

Flexible – emergency managers use creative and innovative approaches in solving disaster challenges.

Professional – emergency managers value a science and knowledge-based approach; based on education, training, experience, ethical practice, public stewardship and continuous improvement.

DISASTER MANAGEMENT

A typical Disaster Management continuum comprising of 4 elements –1. Response 2. Recovery3. Mitigation4. Preparedness in pre-disaster phase

Management sequence of a sudden onset disaster:

Preparedness

ResponseRisk reduction phasebefore a disaster

Rehabilitation

MitigationReconstructionrecovery phase

after a disaster

I. DISASTER IMPACT AND RESPONSE

The impac t phase occurs when the disaster actually happens. It is a time of enduring hardship or injury and of trying to survive. This is a time when individuals help neighbors and families at the scene, a time of "holding on" until outside help arrives. The impact phase might last for several minutes (e.g., during an earthquake, plane crash, or explosion) or for hours, days, or weeks (e.g., in a flood, famine, or epidemic). During the impact phase, injured persons are triaged, morgue facilities are established and coordinated, and search and rescue activities are organized.

Medical treatment for large number of casualties is likely to be needed only after certain types of disaster. Most injuries are sustained during the impact, and thus, the greatest need for emergency care occurs in the first few hours. The management of mass casualties can be further divided into search and rescue, first aid, triage and stabilization of victims, hospital treatment and redistribution of patients to other hospitals if necessary.

Search, rescue and first-aid:After a major disaster, the need for search, rescue and first aid is likely to be so great that organized relief services will be able to meet only a small fraction of the demand. Most immediate help comes from the uninjured survivors.

Disaster

Field care:Most injured persons converge spontaneously to health facilities, using whatever transport is available, regardless of the facilities, operating status. Providing proper care to casualties requires that the health service resources be redirected to this new priority. Bed availability and surgical services should be maximized. Provisions should be made for food and shelter. A centre should be established to respond to inquiries from patient's relatives and friends. Priority should be given to victim's identification and adequate mortuary space should be provided.

Triage:Triage consists of rapidly classifying the injured on the basis of the severity of their injuries and the likelihood of their survival with prompt medical intervention. Higher priority is granted to victims whose immediate or long-term prognosis can be dramatically affected by simple intensive care. Moribund patients who require a great deal of attention, with questionable benefit, have the lowest priority. Triage is the only approach that can provide maximum benefit to the greatest number of injured in a major disaster situation.Although different triage systems have been adopted and are still in use in some countries, the most common classification uses the internationally accepted four color code system. Red indicates high priority treatment or transfer, yellow signals medium priority; green indicates ambulatory patients and black for dead or moribund patients.

Triage should be carried out at the site of disaster, in order to determine transportation priority, and admission to the hospital or treatment centre, where the patient's needs and priority of medical care will be reassessed. Ideally, local health workers should be taught the principles of triage as part of disaster training. Persons with minor or moderate injuries should be treated at their own homes to avoid social dislocation and the added drain on resources of transporting them to central facilities. The seriously injured should be transported to hospitals with specialized treatment facilities.

Five Category Coding for Triage

1. Red—Most urgent; first priority

First-priority patients have life-threatening injuries and are experiencing hypoxia or nearing hypoxia. Examples of injuries in this category include shock, chest wounds, internal hemorrhage, head injuries pro-ducing increased loss of consciousness, partial- or full-thickness burns over 20% to 60% of the body surface, and chest pain.

2. Yellow—Urgent; second priority

Second-priority patients have injuries with systemic effects and complications but are not yet hypoxic or in shock. The patients appear stable enough to withstand up to a 2-hour wait without immediate risk. Examples of injuries in this category include multiple fractures, open fractures, spinal injuries, large lacerations; partial- or full-thickness burns over 10% to 20% of the body surface, and medical emergencies, such as diabetic coma, insulin shock, and epileptic seizure. Patients with second-priority status might need to be observed closely for signs of shock, at which time they would be re-categorized to first priority.

3. Green—Third priority

Third-priority patients have minimal injuries unaccompanied by systemic complications. Usually these patients can wait more than 2 hours for treatment without danger. Examples of injuries in this category in-clude closed fractures, minor bums, minor lacerations, sprains, contusions, and abrasions.

4. Black—Dying or dead

Dying or dead patients are hopelessly injured patients or dead victims. These patients have catastrophic injuries (e.g., crushing injuries to the head or chest) and would not survive under the best of circumstances. These patients create the greatest difficulty, because failure to treat patients conflicts with nursing philosophy. In a disaster, triage must give the chance of survival to the greatest number of victims rather than to one individual. Personnel and equipment must be reserved for the greatest number of viable patients.

5. Contaminated—Might have a color code or a hazardous material (HAZ MAT) triangle tag

These patients are contaminated with bacteriologic or chemical hazards. They will be routed to a decontamination sector to eliminate hazards before additional treatment is provided.

Tagging

All patients should be identified with tags stating their name, age, place of origin, triage category, diagnosis, and initial treatment.

Taking care of dead

Taking care of the dead is an essential part of the disaster management. A large number of dead can also impede the efficiency of the rescue activities at the site of the disaster. Care of the dead includes:

(1) Removal of the dead from the disaster scene;

(2) Shifting to the mortuary;

(3) Identification;

(4) Reception of bereaved relatives. Proper respect for the dead is of great importance.

The health hazards associated with cadavers are minimal if death results from trauma and corps are quite unlikely to cause outbreaks of disease such as typhoid fever, cholera or plague. If human bodies contaminate streams, wells, or other water sources as in floods etc., they may transmit gastroenteritis or food poisoning to survivors. The dead bodies represent a delicate social problem.

RELIEF PHASE

Immediately following a disaster, the most critical health supplies are those needed for treating casualties, and preventing the spread of communicable diseases. Following the initial emergency phase, needed supplies will include food, blankets, clothing, shelter, sanitary engineering equipment and construction material. A rapid damage assessment must be carried out in order to identify needs and resources. Disaster managers must be prepared to receive large quantities of donations. There are four principal components in managing humanitarian supplies

a) Acquisition of supplies;

b) Transportation

c) Storage

d) Distribution.

EPIDEMIOLOGIC SURVEILLANCE AND DISEASE CONTROL

Disasters can increase the transmission of communicable diseases through following mechanisms:

1. Overcrowding and poor sanitation in temporary resettlements. This accounts for the reported increase in acute respiratory infections etc. following the disasters.

2. Population displacement may lead to introduction of communicable diseases to which either the migrant or indigenous populations are susceptible.

3. Disruption and the contamination of water supply, damage to sewerage system and power systems are common in natural disasters.

4. Disruption of routine control programs as funds and personnel are usually diverted to relief work.

5. Ecological changes may favor breeding of vectors and increase the vector population density.6. Displacement of domestic and wild animals, which carry with them zoonoses that can be

transmitted to humans as well as to other animals. Leptospirosis cases have been reported following large floods (as in Orissa India, after super cyclone in 1999). Anthrax has been reported occasionally.

7. Provision of emergency food, water and shelter in disaster situation from different or new source may itself be a source of infectious disease.

Outbreak of gastroenteritis, which is the most commonly reported disease in the post-disaster period, is closely related to first three factors mentioned above. Increased incidence of acute respiratory infections is also common in displaced population. Vector-borne diseases will not appear immediately but may take several weeks to reach epidemic levels.

Displacement of domesticated and wild animals increases the risk of transmission of zoonoses. Veterinary services may be needed to evaluate such health risks. Dogs, cats and other domestic animals are taken by their owners to or near temporary shelters. Some of these animals may be reservoirs of infections such as leptospirosis, rickettsiosis etc. Wild animals are reservoirs of

infections which can be fatal to man such as equine encephalitis, rabies, and infections still unknown in humans.

The principles of preventing and controlling communicable diseases after a disaster are;

Implement as soon as possible all public health measures, to reduce the risk of disease transmission

Organize a reliable disease reporting system to identify outbreaks and to promptly initiate control measures

Investigate all reports of disease outbreaks rapidly Vaccination

Health authorities are often under considerable public and political pressure to begin mass vaccination programmes, usually against typhoid, cholera and tetanus. The pressure may be increased by the press media and offer of vaccines from abroad.

The WHO does not recommend typhoid and cholera vaccines in routine use in endemic areas. The newer typhoid and cholera vaccines have increased efficacy, but because they are multi dose vaccines, compliance is likely to be poor. They have not yet been proven effective, as a large-scale public health measure. Vaccination programme requires large number of workers who could be better employed elsewhere. Supervision of sterilization and injection techniques may be impossible, resulting in more harm than good. And above all, mass vaccination may lead to false sense of security about the risk of the disease and to the neglect of effective control measures. However, these vaccinations are recommended for health workers. Supplying safe drinking water and proper disposal of excreta continue to be the most practical and effective strategy.

Significant increase in tetanus incidence has not occurred after natural disasters. Mass vaccination of population against tetanus is usually unnecessary. The best protection is maintenance of a high level of immunity in the general population by routine vaccination before the disaster occurs, and adequate wound cleaning and treatment.

Natural disasters may negatively affect the maintenance of ongoing national or regional eradication programmes against polio and measles. Disruption of these programmes should be monitored closely. If cold-chain facilities are inadequate, they should be requested at the same time as vaccines. The vaccination policy to be adopted should be decided at senior level only.

NUTRITION

A natural disaster may affect the nutritional status of the population by affecting one or more components of food chain depending on the type, duration and extent of the disaster, as well as the food and nutritional conditions existing in the area before the catastrophe. Infants, children, pregnant women, nursing mothers and sick persons are more prone to nutritional problems after prolonged drought or after certain types of disasters like hurricanes, floods, land or mudslides, volcanic eruptions and sea surges involving damage to crops, to stocks or to food distribution systems.

The immediate steps for ensuring that the food relief programme will be effective include : (a) assessing the food supplies after the disaster ; (b) gauging the nutritional needs of the affected

population ; (c) calculating daily food rations and need for large population groups ; and (d) monitoring the nutritional status of the affected population.

REHABILITATION

The final phase in a disaster should lead to restoration of the pre-disaster conditions. Rehabilitation starts from the very first moment of a disaster. Too often, measures decided in a hurry, tend to obstruct re-establishment of normal conditions of life. Provisions by external agencies of sophisticated medical care for a temporary period have negative effects. On the withdrawal of such care, the population is left with a new level of expectation which simply cannot be fulfilled.

In first weeks after disaster, the pattern of health needs will change rapidly, moving from casualty treatment to more routine primary health care. Services should be reorganized and restructured. Priorities also will shift from health care towards environmental health measures. Some of them are as follows :

i. water supply

A survey of all public water supplies should be made. This includes distribution system and water source. It is essential to determine physical integrity of system components, the remaining capacities, and bacteriological and chemical quality of water supplied.

The main public safety aspect of water quality is microbial contamination. The first priority of ensuring water quality in emergency situations is chlorination. It is the best way of disinfecting water. It is advisable to increase residual chlorine level to about 0.2-0.5 mg / litre. Low water pressure increases the risk of infiltration of pollutants into water mains. Repaired mains, reservoirs and other units require cleaning and disinfection.

Chemical contamination and toxicity are a second concern in water quality and potential chemical contaminants have to be identified and analyzed.

The existing and new water sources require the following protection measures

(1) Restrict access to people and animals, If possible, erect a fence and appoint a guard

(2) Ensure adequate excreta disposal at a safe distance from water source

(3) Prohibit bathing, washing and animal husbandry, upstream of intake points in rivers and streams

(4) Upgrade wells to ensure that they are protected from contamination

(5) Estimate the maximum yield of wells and if necessary, ration the water supply

In many emergency situations, water has to be trucked to disaster site or camps. All water tankers should be inspected to determine fitness, and should be cleaned and disinfected before transporting water.

ii. Food safety

Poor hygiene is the major cause of food-borne diseases in disaster situations. Where feeding programmes are used (as in shelters or camps) kitchen sanitation is of utmost importance. Personal hygiene should be monitored in individuals involved in food preparation.

iii.Basic sanitation and personal hygiene

Many communicable diseases are spread through faecal contamination of drinking water and food. Hence, every effort should be made to ensure the sanitary disposal of excreta. Emergency latrines should be made available to the displaced, where toilet facilities have been destroyed. Washing, cleaning and bathing facilities should be provided to the displaced persons.

iv.Vector control

Control programme for vector-borne diseases should be intensified in the emergency and rehabilitation period, especially in areas where such diseases are known to be endemic. Of special concern are dengue fever and malaria (mosquitoes), Ieptospirosis and rat bite fever (rats), typhus (lice, fleas), and plague (fleas). Flood water provides ample breeding opportunities for mosquitoes.

A major disaster with high mortality leaves a substantial displaced population, among whom are those requiring medical treatment and orphaned children. When it is not possible to locate the relatives who can provide care, orphans may become the responsibility of health and social agencies. Efforts should be made to reintegrate disaster survivors into the society, as quickly as possible through institutional programmes coordinated by ministries of health and family welfare, social welfare, education, and NGOs.

II. RECOVERY PHASE

The aim of the recovery phase is to restore the affected area to its previous state. It differs from the response phase in its focus; recovery efforts are concerned with issues and decisions that must be made after immediate needs are addressed. Recovery efforts are primarily concerned with actions that involve rebuilding destroyed property, re-employment, and the repair of other essential infrastructure. Efforts should be made to "build back better", aiming to reduce the pre-disaster risks inherent in the community and infrastructure. An important aspect of effective recovery efforts is taking advantage of a ‘window of opportunity’ for the implementation of mitigative measures that might otherwise be unpopular. Citizens of the affected area are more likely to accept more mitigative changes when a recent disaster is in fresh memory.

This phase begins when assistance from outside starts to reach the disaster area. The type and quantity of humanitarian relief supplies are usually determined by two main factors:

(1) The type of disaster, since distinct events have different effects on the population

(2) The type and quantity of supplies available locally.

III. MITIGATION

Mitigation efforts are attempts to prevent hazards from developing into disasters altogether or to reduce the effects of disasters. The mitigation phase differs from the other phases in that it focuses on long-term measures for reducing or eliminating risk. The implementation of mitigation strategies is a part of the recovery process if applied after a disaster occurs. Mitigation measures can be structural or non-structural. Structural measures use technological solutions like flood levees. Non-structural measures include legislation, land-use planning (e.g. the designation of nonessential land like parks to be used as flood zones), and insurance. Mitigation is the most cost-

efficient method for reducing the affect of hazards although not always the most suitable. Mitigation includes providing regulations regarding evacuation, sanctions against those who refuse to obey the regulations (such as mandatory evacuations), and communication of risks to the public. Some structural mitigation measures may harm the ecosystem.

A precursor to mitigation is the identification of risks. Physical risk assessment refers to identifying and evaluating hazards. The hazard-specific risk (Rh) combines a hazard's probability and affects. The higher the risk, the more urgent that the vulnerabilities to the hazard are targeted by mitigation and preparedness. If, however, there is no vulnerability then there will be no risk, e.g. an earthquake occurring in a desert where nobody lives.

Based on risk assessment, specific action plans should be designed to reduce the effects of predicted disasters. Mitigation might involve legislating specific building codes and land-use restrictions. Assessment and inventory of resources for special equipment, «applies, and personnel necessary to support an emergency response is essential. Planning activities should be coordinated by the emergency management agency and involve all appropriate government agencies, public safety, private organizations, and health care entities. Disaster plans and personnel training must be reviewed and tested on a regular basis. % critical component of the pre-disaster phase preparation is education of the public to encourage individual preparedness. Examples of public education are the hurricane watch preparation and evacuation procedures for communities in the Southeast hurricane belt.

IV. DISASTER PREPAREDNESS

Emergency preparedness is "a programme of long term development activities whose goals are to strengthen the overall capacity and capability of a country to manage efficiently all types of emergency. It should bring about an orderly transition from relief through recovery, and back to sustained development”.

The objective of disaster preparedness is to ensure that appropriate systems, procedures and resources are in place to provide prompt effective assistance to disaster victims, thus facilitating relief measures and rehabilitation of services.The individuals are responsible for maintaining their well- being. Community members, resources, organizations, and administration should be the cornerstone of an emergency preparedness programme. The reasons of community preparedness are:

(a) Members of the community have the most to lose from being vulnerable to disasters and the most to gain from an effective and appropriate emergency preparedness program

(b) Those who first respond to an emergency come from within the community. When transport and communications are disrupted, an external emergency response may not arrive for days

(c) Resources is most easily pooled at the community level and every community possesses capabilities. Failure to exploit these capabilities is poor resource management

(d) Sustained development is best achieved by allowing emergency-affected communities to design, manage, and implement internal and external assistance programme

Disaster preparedness is an ongoing multi sectoral activity. It forms an integral part of the national system responsible for developing plans and programmes for disaster management, prevention,

mitigation, preparedness, response, rehabilitation and reconstruction. The system, known by a variety of names depending on the country, depends on the coordination of a variety of sectors to carry out the following tasks

Evaluate the risk of the country or particular region to disaster; Adopt standards and regulations ; Organize communication, information and warning systems ; Ensure coordination and response mechanisms ; Adopt measures to ensure that financial and other resources are available for increased

readiness and can be mobilized in disaster situation ; Develop public education programmes ; Coordinate information sessions with news media ; and Organize disaster simulation exercises that test response mechanisms.

Policy development:

The policy development is "the formal statement of a course of actionn. Policy is strategic in nature and performs the following functions:

establish long - term goals; assign responsibilities for achieving goals; establish recommended work practice; and Determine criteria for decision making.

While policies tend to be “top - down" that is authorized by higher levels, implementation of the strategies that arise from a policy tend to be "bottom-up", with the higher levels assisting lower levels. The form of emergency preparedness policy varies from country to country. Six sectors are required for response and recovery strategies. These sectors are communication, health, social welfare, police and security search and rescue and transport.

NEW CHALLENGES FOR DISASTER PLANNING AND RESPONSE

The recent acts of biological terrorism (bioterrorism) and chemical terrorism using biological and chemical agents as weapons to inflict death, injuries, property damage, and disruption of public services have created the need to reexamine disaster plans at all levels of government and public health agencies. All public safety, public health, and health care organizations must work closely together to develop plans, train personnel, educate the professional responders and the public on use of protective equipment, and develop communication models. Nurses practicing in all health care settings need to be involved in disaster planning and receive disaster response education and training (Kennedy, 2001; Riley, 2003).

Bioterrorism

There are special characteristics of biologic agents that are used by terrorists. The biological agent must be capable of causing morbidity, and possible mortality and/or cause a disease that is difficult to diagnose and treat. The fear factor is important to the terrorist; therefore, the more severe the morbidity and mortality, the greater the fear factor. Other characteristics of the agent that must be considered by the terrorist are (1) accessibility, (2) reproducibility, (3) stability, and (4) dispersibility (Brachman, 2002). Potential biological agents have been categorized based on their characteristics.

An early, effective response to a bioterrorism act depends on the quality of health surveillance. There must be a routine, mandatory, timely reporting of certain illnesses by laboratories, schools, hospitals, and other health care facilities. Routine reporting creates challenges. The routine reporting from medical laboratories is highly reliable; however, there are many weaknesses in timely reporting from public health agencies, and health care providers. Methods for secondary surveillance that exist in some local communities and state health departments include monitoring sales of over-the-counter medicines, monitoring diseases in animals, and monitoring emergency- department ambulance diversions; however, this information is not usually timely and may have a lag time of weeks to months. In planning an effective defense against bioterrorism, new models of surveillance that yield timely information must be developed. Syndromic surveillance is an example of a model that includes syndromes such as dyspnea, pneumonia, rash, nausea and/or vomiting, diarrhea, encephalitis, and other unexplained or unusual illnesses or deaths (Brachman, 2002) . This type of surveillance can be helpful because many potential bioterrorism agents cause similar symptoms. For example, fever, malaise, and cough are symptoms that can result from inhalational anthrax, pneumonic plague, and/or tularemia.

Chemical and Hazardous Materials

The Agency for Toxic Substances and Disease Registry (ATSDR), an agency of the U.S. Department of Health and Human Services, protects the public from hazardous wastes and environmental spills of hazardous substances. ATSDR is the lead agency within the Public Health Service to help prevent or reduce further exposure to hazardous substances. Its functions include public health as- *v>mcnts of waste sites; health consultations concerning specific hazardous substances; health surveillance and registries; and education and training concerning hazardous substances.

The ATSDR has prepared an education and training series, Manag ing Hazardous Material Incidents (MHMI), for rescue and health care workers. The MHMI books and video pro- vide recommendations for on scene (pre hospital) and hospital medical management of patients exposed during a hazardous materials incident. This information is available on the ATSDR website (see Community Resources for Practice at the end of the chapter to access this site).

The ATSDR operates a surveillance system for chemical and hazardous substance. This system is known as the Hazardous Substances Emergency Events Surveillance (HSEES) system.

Health care providers must be aware of these chemical and hazardous substance threats and know how to access information on self-protection from contamination and the appropriate client decontamination and treatment measures for the specific contaminate. Planning for chemical and hazardous substance contamination must be part of all health care agencies9 disaster planning and training.

INTERNATIONAL ORGANIZATIONS

International Association of Emergency Managers

The International Association of Emergency Managers (IAEM) is a non-profit educational organization dedicated to promoting the goals of saving lives and protecting property during

emergencies and disasters. The mission of IAEM is to serve its members by providing information, networking and professional opportunities, and to advance the emergency management profession. It currently has seven Councils around the World: Asia, Canada, Europa, International, Oceania, Student and USA

IAEM also administrates the following programs on behalf of the profession: Certified Emergency Manager (CEM) Scholarship Program

The Air Force Emergency Management Association :loosely affiliated by membership with the IAEM, provides emergency management information and networking for US Air Force Emergency Managers.

Red Cross/Red Crescent

National Red Cross/Red Crescent societies often have pivotal roles in responding to emergencies. Additionally, the International Federation of Red Cross and Red Crescent Societies (IFRC, or "The Federation") may deploy assessment teams, e.g. [4] Field Assessment and Coordination Team - (FACT) to the affected country if requested by the national Red Cross or Red Crescent Society. After having assessed the needs Emergency Response Units (ERUs) may be deployed to the affected country or region. They are specialized in the response component of the emergency management framework.

United Nations

Within the United Nations system responsibility for emergency response rests with the Resident Coordinator within the affected country. However, in practice international response will be coordinated, if requested by the affected country’s government, by the UN Office for the Coordination of Humanitarian Affairs (UN-OCHA), by deploying a UN Disaster Assessment and Coordination (UNDAC) team.

World Bank

Since 1980, the World Bank has approved more than 500 operations related to disaster management, amounting to more than US$40 billion. These include post-disaster reconstruction projects, as well as projects with components aimed at preventing and mitigating disaster impacts, in countries such as Argentina, Bangladesh, Colombia, Haiti, India, Mexico, Turkey and Vietnam to name only a few.[18]

Common areas of focus for prevention and mitigation projects include forest fire prevention measures, such as early warning measures and education campaigns to discourage farmers from slash and burn agriculture that ignites forest fires; early-warning systems for hurricanes; flood prevention mechanisms, ranging from shore protection and terracing in rural areas to adaptation of production; and earthquake-prone construction.[19]

In a joint venture with Columbia University under the umbrella of the ProVention Consortium the World Bank has established a Global Risk Analysis of Natural Disaster Hotspots.[20]

In June 2006, the World Bank established the Global Facility for Disaster Reduction and Recovery (GFDRR), a longer term partnership with other aid donors to reduce disaster losses by mainstreaming disaster risk reduction in development, in support of the Hyogo Framework of Action. The facility helps developing countries fund development projects and programs that enhance local capacities for disaster prevention and emergency preparedness.[21]

European Union

Since 2001, the EU adopted Community Mechanism for Civil Protection which started to play a significant role on the global scene. Mechanism's main role is to facilitate co-operation in civil protection assistance interventions in the event of major emergencies which may require urgent response actions. This applies also to situations where there may be an imminent threat of such major emergencies.

The heart of the Mechanism is the Monitoring and Information Centre. It is part of Directorate-General for Humanitarian Aid & Civil Protection of the European Commission and accessible 24 hours a day. It gives countries access to a platform, to a one-stop-shop of civil protection means available amongst the all the participating states. Any country inside or outside the Union affected by a major disaster can make an appeal for assistance through the MIC. It acts as a communication hub at headquarters level between participating states, the affected country and despatched field experts. It also provides useful and updated information on the actual status of an ongoing emergency.[22]

International Recovery Platform

The International Recovery Platform (IRP) was conceived at the World Conference on Disaster Reduction (WCDR) in Kobe, Hyogo, Japan in January 2005. As a thematic platform of the International Strategy for Disaster Reduction (ISDR) system, IRP is a key pillar for the implementation of the Hyogo Framework for Action (HFA) 2005–2015: Building the Resilience of Nations and Communities to Disasters, a global plan for disaster risk reduction for the decade adopted by 168 governments at the WCDR.

The key role of IRP is to identify gaps and constraints experienced in post disaster recovery and to serve as a catalyst for the development of tools, resources, and capacity for resilient recovery. IRP aims to be an international source of knowledge on good recovery practice.

NATIONAL ORGANIZATIONS

India

The role of emergency management in India falls to National Disaster Management Authority of India, a government agency subordinate to the Ministry of Home Affairs. In recent years there has been a shift in emphasis from response and recovery to strategic risk management and reduction, and from a government-centered approach to decentralized community participation. The Ministry of Science and Technology supports an internal agency that facilitates research by bringing the academic knowledge and expertise of earth scientists to emergency management.

A group representing a public/private partnership has recently been formed by the Government of India. It is funded primarily by a large India-based computer company and aimed at improving the general response of communities to emergencies, in addition to those incidents which might be described as disasters. Some of the groups' early efforts involve the provision of emergency management training for first responders (a first in India), the creation of a single emergency telephone number, and the establishment of standards for EMS staff, equipment, and training. It operates in three states, though efforts are being made in making this a nation-wide effective group.

KERALA STATE DISASTER MANAGEMENT PLAN

Kerala State is vulnerable in varying degrees to a large number of natural and man-made disasters of recurrent nature that result in loss of life, livelihoods, infrastructure and property, and cause immense hardships to the affected population, besides resulting in disruption of economic activity. The increasing vulnerabilities due to a variety of factors such as rapid urbanization, environmental degradation, growing population and climate change compounded the disaster risks in the State and this mandated a paradigm shift from a relief centric approach to a proactive and comprehensive mindset towards disaster management covering all aspects from prevention, mitigation, preparedness to response and recovery. The enactment of Kerala State Disaster Management Rules, 2007 and promulgation of Kerala State Disaster Management Policy, 2010 in line with National DM Act, 2005 marked defining steps towards holistic disaster management in the State. The Disaster Management Act, 2005 provides that there shall be a plan for disaster management for every State to be called the State Disaster Management Plan’ and enjoins upon the State Government to make provisions for financing the activities to be carried out under the State Plan.The state of Kerala is vulnerable to a multitude of hazards and is categorized as a multiple-hazard prone state. The state experiences various kinds of disasters of recurrent nature that results in loss of life, livelihood and property, and disruption of economic activity, besides causing immense hardship to the affected population. Specific vulnerabilities of the state include,

Floods Landslide- commonly occur in localised areas of the Western Ghats Coastal hazards: 9 districts are bordering the sea coast vulnerable tovarious disasters

such as floods, cyclones, coastal erosion, landslides etc. Lightning- not common Draught Tsunami-26 December 2004. Boat/ rail/ road accidents: eg. Perumon Tragedy, Thattekkad -Periyar River accident,

Kadalundi River rail disaster Earth quakes –occasional mild tremors Industrial & Chemical Disasters

STATE RESPONSE PLAN

The Disaster Response involves emergency search, rescue and relief measures taken in anticipation of, during and immediately in the aftermath of a disaster to ensure that the effects of the disaster are minimized. The overall response strategy will vary from level to level of the disaster (L0, L1, L2, and L3) based on the ability of various authorities to deal with them. The State will remain in readiness to provide assistance if needed in an L1 specified disaster that can be managed at the district level. The State will actively participate, mobilize resources at the state level and will provide assistance to the respective District Disaster Management Authorities in disasters in the category of L2. Even though there cannot be water tight compartmentalization of responsibilities between districts and the State, the participation of the State will normally be at the L2 level disaster.

ROLES AND RESPONSIBILITIES OF STAKEHOLDERS

State AdministrationAs and when a crisis situation is developed, the District Collector will flash the first information‘ to the State Administration / Crisis Management Group and stimulate crisis management activities under the guidance of State Crisis Management Group. The Principal Secretary, Department of Revenue and Disaster Management as convener of State Crisis Management Group would recommend to the State Government or State Disaster Management Authority if the event needs to be declared as a state disaster (L2 Disaster).The Kerala State Disaster Management Authority will facilitate, co-ordinate and monitor the activities in the response phase. The Kerala State Disaster Management Authority would, if required, co-ordinate with agencies of other states and other national and international agencies to supplement the relief being provided. The Crisis Management Group and Incident Response System at the state level will be activated in this phase as Chief Secretary / Principal Secretary of respective nodal department as the Responsible Officer. Each department would perform their respective responsibilities as per the Emergency Support Function under the Incident Response System.

Departments of State Government: The relevant government nodal departments shall carry out search, rescue and immediate relief operations as per the Departmental Disaster Management Plans and District Disaster Management Plans under the overall supervision of State Disaster Management Authority.

District Disaster Management AuthorityThe District Disaster Management Authority headed by the District Collector will activate all the institutional arrangements for disaster response in this phase as per the District Disaster Management Plan.

Local Authorities The Local Authorities including Municipal Corporations, Municipalities and District, Block and Gram Panchayath would work in close coordination with State Disaster Management Authority and relevant government departments in performing the key activities of this phase catering to the immediate requirements of affected population. Non-Governmental Organizations and Private Sector: The human, material, technical and financial resources of Non-Governmental Organizations’ and the private sector shall be mobilized

to provide immediate relief to the affected people. They shall also support the relief efforts of the State Government through supply of emergency search and rescue items, hardware items like generators, pumps, industrial equipments etc. along with deployment of skilled technicians and volunteers.

State Incident Response System The Incident Response System is an organized system of government departments and other agencies that are to be worked under a structured pattern for response and immediate recovery. The Incident Response System provides a structure under which all the line departments will function in tandem with the District and State Administration and lays down various tasks that may need to be performed by the existing administrative machinery at various levels. Departments and external agencies are grouped into various Emergency Support Functions‘under the system. The State Administration will provide necessary support to the District Administrations, if Districts are overwhelmed in any situation, as the initial efforts would always be taken by the District Administration in any disaster response. In order to clearly demarcate proper coordination of the various response efforts at the State level with that of the District, the structure of the Incident Response System in the context of State response is formed and given below.

Responsible Officer (Chief Secretary / Principal Secretary of Nodal Dept)  HQ Incident Response Team State EOC

INCIDENTCOMMANDER INCIDENTCOMMANDER IRT District – A IRT District – B

The Organizational structure, particularly the HQ Incident Response Team of Incident Response System at the State level will be activated only in a State level disaster and Responsible Officer will involve all required Emergency Support Functionaries (ESF) and Headquarters Incident Response Team (IRT) to support the on-scene Incident Commander who will work in close coordination with State EOC and report to Responsible Officer.

Emergency Support Functions (ESF)A crisis situation demands the intervention and assistance of experts from different

departments / fields in order to ensure a quick and effective recovery. Keeping this aspect of disaster management in view, Emergency Support Functions have been conceptualized to take care of various response actions. Each Emergency Support Function is headed by a lead department and the designated primary agency will be assisted by one or more support agencies (secondary agencies) and will be responsible for managing the activities of the Emergency Support Function. Nodal officers of all the ESFs would constitute and employ Incident Response Team who will accomplish the response actions at the field level. Similarly supporting agencies would also assign their nodal officers and IRT members will assist the primary officers during response. The relevant departments/ agencies shall draw up Emergency Support Function Plans and constitute Incident Response Teams and designate resources in advance. Pre contract/ agreement can be made for all disaster relief items so as to avoid delays in procuring relief items after disaster situation.

ESF1. Coordination (warning, evacuation, relief, shelter, damage assessment, GO/volunteers Coordination) 

Establishment of evacuation plans / Identification of fastest evacuation routes and all alternative routes.

Coordinate search and rescue logistics during field operation Immediate arrangement of food and relief materials during the crisis. Ensure coordination of activities involved with the emergency provisions of temporary

shelters, emergency mass feeding and bulk distribution of relief supplies to the disaster victims

Control quality and quantity of food for relief/ Ensure timely distribution Provide adequate and appropriate shelter to all population / Locate relief camps close to

open traffic and transport links. Develop alternate arrangements for population living in structures that might be affected

even after the disaster. Encourage various voluntary agencies and organizations to depute the volunteers / Gather

general youth mass to volunteer / Operation wise categorize the volunteers /  Identify any specialized skills and area of interest among volunteers.

Arrange of mass donations of monetary resource, food, clothes, medicines, essential items, cattle feed, and cattle medicines.

Maintain a record of donations and its supply to the needy area. In coordination with relevant depts. Assess the Number of lives lost, Number of People

Affected, Number of Houses damaged (category wise), Damage of Infrastructures like School, Hospitals, Govt. Buildings, Road, Electricity, Water Supply etc.

2. Communication 

Restore Communication facilities after disaster Provide emergency communication for response to government: link affected sitewith

DEOC/DEOC with other Departments etc. Provide communication facility to affected communities Coordinate the requirements of temporary telecommunication in affected areas.

3 Search & rescue Establish, maintain and manage search and rescue operations. Coordinate search and rescue logistics during a field operation

4 Law & Order Primary Functions: Maintaining law and order (crowd control, riot/looting control, preventive arrests). Assisting the authorities in un-interrupted relief operations Coordinate the requirements of temporary telecommunication in affected areas.

5 Medical Response Primary Functions:

Direct activation of medical personnel, supplies and equipments. Activation of Mobile Medical teams with first aid & Mobilize emergency treatment for the

injured people. Appropriate mass vaccination to check the waterborne epidemics. Set up Trauma Counseling Desks. Perform medical evaluation and treatment as needed. Maintain patient tracking system to keep record of all patients treated.

6 Public Works (debris/road clearance, equipment support) Primary Functions: Restore the road communication system / Assess the damage for reconstruction of road

ways Restore the infrastructure like health centers, school, important buildings, Initiate the reconstructions unrecoverable important infrastructures Emergency clearance of Debris Coordinate and provide manpower and equipments for debris and road clearance Provide alternative routes, if main routes are affected Demolish unsafe buildings

7 Public Information/Help lines/NGO coordination Primary Functions: Provide and collect reliable information on the status of the disaster / disaster victims for

effective coordination of relief work  Setting up of toll free numbers for emergency information assistance / Establish help lines

for providing, directing and coordinating logistical operations. Process and disseminate information / Manage flow of information and warning

dissemination. Provide a platform for NGO coordination

8 Logistics (Water, Electricity & Transportation) Primary Functions: Ensure smooth transportation links Restoration of power supply or temporary power supply to critical areas. Facilitate restoration of electricity distribution systems at most affected sites

on priority to help in Search and Rescue operations. Provide electricity in lifeline buildings. Delivery of clean drinking water

Transportation of relief/relief parties/affected community. Ensure quick restoration of drainage system.

DISASTER NURSING

In response to disasters, natural and man-made, a specialty within the area of critical care nursing has emerged. Disaster nursing involves readiness and preparedness in responding to immediate community needs during and after a catastrophic event. Catastrophic events are extremely overwhelming to any community. It's not just the high mortality rate. Damage to roads, buildings and electrical services profoundly limit a region's capacity to respond. Paramedics and police, fire

and hospital emergency departments become overburdened. Government organizations are quickly inundated with requests for aid and other immediate relief.

HistoryThe historical background of disaster nursing is based in military nursing. Throughout most of history, nurses have been present in wartime, offering support and solstice to those bloodied in battle. During the Crimean War, Florence Nightingale assembled a staff of 38 volunteer nurses to care for wounded soldiers. They were receiving poor care due to the overburdened medical staff. Supplies were short and infection rampant. With the help of the nurses, mortality decreased, as did instances of infection. Many of the protocols that were implemented later became prominent health care models later on.

Significance

The role of the critical care nurse during these kinds of situations can cover a wide area of responsibility: medical history and physical assessment, psychosocial assessment and referral to mental health services. In addition to giving medical treatment, disaster nurses also provides emotional support to families, children and the elderly, and assists with rumor control. They make quick decisions about who will get treatment first. They often must decide who will receive care when supplies are low or have run out. However, their first priority is always to treat the walking wounded. Then they are able to be of some assistance to the nurses and other medical staff as needed.

DISASTER NURSING - ROLES OF NURSING SERVICE ADMINISTRATION

An important part of preparing nurses for a mass casualty event is providing education about the types and number of injuries that are expected, and the capacity of the facility. Knowledge and practice enable the nurses to maintain a level of control in a situation that may appear as chaos.

1. Institutional Readiness

A key component in institutional readiness is getting involved in local planning. During the implementation of the response plan, the value of using these templates is evident, as they aid in examining the appropriateness and adequacy of physical facilities, organizational structure, human resources, and communication systems.

Government funding has also supported adequate response efforts following a disaster. A primary concern following a mass casualty event is the determination of surge capacity. Surge capacity is an estimation of the maximum patient load of responding hospitals and includes beds, staffing, equipment, and EMS systems. Each facility must be able to determine their ability to manage casualties quickly so that victims will be sent to the most appropriate facility.

2. Staffing NeedsWhen a mass casualty event is announced or suspected, supervisors or designated nurse managers must begin the process of determining staffing needs. This process begins with the confirmation of exactly how many nurses are currently on duty, as well as their type and skill

level. Nurse Managers should then begin the relocation of staff according to the response plan. After determining the number of staff reporting to the ED, it is time to begin the call-up of needed staff that are not currently on duty (Newberry, 2002). Throughout the day and on all shifts, specific nurses should be identified as authorities. The d i s t r i bu t i on of nurses should be based on their skill level, such as intensive care nurses, outpatient setting nurses, and operating or emergency department nurses.

3. Assignment and Rotation of Nursing Staff

It may be difficult for necessary employees to get to the hospital or clinic due to traffic congestion or interruption. Develop a plan for these necessary employees, such as p i ckup points located throughout the area, and van services to transport employees to the agency. Communicate frequently with staff members, updating them with accurate knowledge about what the disaster is, how many patients may be coming, and when they will start to arrive.

At the time of a mass casualty event, there must be a coordinated use of staff to ensure their continued availability for the duration of the crisis.

4. Mobilization of ResourcesAs soon as the disaster has been announced, and casualties are anticipated, nurses should begin the relocation of supplies to the designated triage and decontamination areas. These supplies should be dedicated to disaster response only, not used as a backup supply reservoir for individual units. To familiarize nurses with the amount, location, and type of supplies and medications on the carts, staff nurses should share the responsibility of checking the content of the can and rotating supplies with an approaching expiration date to the general stock and replacing them with newer stock.

5. Agency ProtectionIn addition to secondary injuries incurred while caring for casualties from the event or agents used in the event, agencies must protect themselves against direct attacks.

If a chemical agent is suspected and decontamination is anticipated, all staff coming in contact with victims before they have been decontaminated must wear PPE. This includes impermeable clothing, gloves, hoots, and a £as mask. Education for nurses must incorporate time for practice in donning the PPE, and should be a part of the disaster exercises held by each agency and community.

Managers must evaluate the practicality of using nurses for the decontamination procedure. Consider assigning unlicensed personnel or nursing students who, with training, may be used outside to decontaminate the more stable victims. This frees the nursing staff to address the more complex care issues inside the hospital, where unlicensed personnel would be unable to assist.

6. Management of Events

During an incident, it is important to evaluate the physical plan of the institution or agency. When examining a possible flow pattern during a mass casualty event, it is imperative that all responders are familiar with the flow pattern at your agency. If victims are being transported randomly to various departments, a traffic jam or bottleneck may result. A

suggestion made is that all victims go in one direction when leaving the ED; no victims return, rather they progress to the next area. Areas that are potential bottlenecks are X ray, CT, ultrasound, and laboratory areas. In addition, areas requiring intensive interventions, such as airway management, table thoracostomy, and blood transfusions, may also slow the flow of patients.

7. Determining Capacity

Those in authority must be able to quickly determine hospitalization capacity, status of critical care beds, how many casualties they can handle, how many operating rooms are available, and how many ventilators are unused. Nearby schools and hotels may provide efficient and necessary space for victims. How One of the more impressive preparations of hospitals is the plan to empty the emergency department and set up outpatient surgery as an ED extension within 10 to 15 minutes. Nurses are categorized according to a tier system so that they know when they are required to come to the hospital in case of a mass casualty event.

8. CommunicationEffective communication is vital during times of disaster. Those involved in the

disaster response must be able to communicate with each other and coordinate their ef-forts. If utilities are disabled or destroyed, many forms of traditional communication are lost. These include telephone, FAX, and Internet access. Today we are technology dependent, and this becomes critical when communication systems are disabled.

9. Casua l t y Managemen t Preparations of CareCertain types of injuries can he anticipated depending on the type of event. For

example, conventional weapons result in blast injuries. If this is an industrial accident, the chemical may be known. In a terrorist attack, there may be a period of time when the agent is unknown and the institutions must be prepared to provide care in this situation. A mass transportation accident, a building collapse, a natural disaster such as an earthquake or a tornado poses unique challenges to preparation and care. Maintaining contact with first re-sponded on the scene of the event will enable the hospital or agency to prepare for the specific victims of that type of disaster. Another issue to be addressed prior to need is the acquisition of adequate supplies of blood for the treatment of casualties.

10. Unit OrganizationIt is imperative that adequate supplies are available to handle large numbers of

casualties. Each facility prepares to accept large numbers of casualties without depleting everyday supplies. This involves the placement of supply carts throughout the area near the emergency department. There are several types of supply carts that should be prepared. These include carts containing the supplies necessary to decontaminate the victims of chemical contamination, as well as medical supplies for treatments, such as dressings, tape, procedure-related items, intravenous needles, catheters, and syringes. Unit organization

includes daily assignment of personnel responsible for moving these carts to the designated areas if a disaster occurs.

11. Patient Tracking

One of the issues facing all health care facilities is the identification and tracking of patients. Pre-assembled medical records should be located throughout the Emergency Department. Staff must be able to identify people as soon as possible after they arrive for care, because patients must be moved rapidly and efficiently through the triage and decontamination areas, and into the facility for indicated treatments and procedures. The prepared medical records are opened using an identification system. The system does not need to be elaborate. A simple system such as each record containing adhesive number sheets is adequate, so that all treatment information, testing, and follow-up are documented using these numbers. As soon as possible after the patient enters the hos-pital; more traditional identification procedures can be enacted.

DISASTER NURSING MAINLY FOCUSES ON THE FOLLOWING AREAS:

Pre-Planning: Developing a Response Plan

A response plan should be concerned with delivering emergency health care as efficiently and as quickly as possible. To that end, community nurses should know in advance all community medical and social agency resources that will be available during a disaster. They should know where equipment and supplies have been stored and their prearranged role and rendezvous site.

Most agencies have a disaster notification network to alert personnel. Staff must follow a protocol of notification so that all available personnel are alerted or called to duty when the need arises. A good notification network should include a contingency plan for cases in which some personnel might not be reachable. If possible, when disasters are predictable or probable, health care personnel should be pre- warned or placed on alert. Having personnel on alert status reduces the response time during the actual disaster.

Another important element of a response plan is the designation of an alternative reporting site for health care workers. In the event of a major disaster, some designated sites might be destroyed or damaged. A good plan will include alternative response sites to which workers can report.

Emergency personnel should be v e ry f ami l i a r with the equipment and supplies they will use in the event of an actual disaster. In addition to mock disaster drills, which allow personnel to practice procedures and set up equipment, a periodic check of equipment and supplies should be part of the response plan. Some of the supplies are perishable and need to be restocked at regular intervals.

Emergency personnel responding to a disaster site must have the appropriate personal protective equipment and have knowledge of how to use this equipment. In addition, the emergency responders need to have previous training and knowledge of assessing potential hazards at the

1ГЧ

N

disaster site, such as unstable building structures, possible explosive hazards, and chemical or other hazardous substances.

Community Preparedness

Community preparedness for disaster events should be part of the planning preparation. Community health nurses, ARC, and other volunteer nurses provide education programs. Public education is directed toward safety, self-help, and first-aid measures. A good education program should include information about proper storage of food and water, rotation of canned goods to ensure use before expiry dates, and safety precautions for water use (e.g., boiling water if equipment is available or using bottled water when plumbing is not working or tap water is not safe to drink).

A good first-aid program should include information about the types of supplies needed in a home first-aid kit .First-aid courses help the public become prepared to address trauma injuries, such as fractures, bleeding, and burns. Although the general public cannot be prepared to deal with sophisticated injuries, a sound knowledge of first aid will help most families cope with the most likely injuries in a disaster situation.

Every family in the community should be encouraged to develop a personal preparedness plan .Family members should have a prearranged site at which to reassemble in case they are forced to evacuate a dwelling from different exits. This simple plan can save confusion and the unnecessary injuries that often occur when family members attempt to re-enter a dwelling to look for others who have already evacuated. Every home should store the following items in a designated location:

Emergency telephone numbers Battery-operated radio Working flashlight First-aid kit Three-day supply of water Medical information (allergies, blood types, prescription medications) Physician names, addresses, and telephone numbers Persons to be notified in an emergency

Prearranged supplies and personal information make it more likely the items will be easily located in case of an emergency or evacuation.

Residents should be alerted to the types of supplemental supplies that could ease shelter living in the event of an evacuation order. A survey of evacuees during Hurricane Elena indicated items, such as food, blankets, pillows, prescription medication, personal grooming items, portable chairs, and a radio, would have improved comfort in the shelter (Brown et al., 1988). Special care items for infants, elderly, or disabled family members (e.g., diapers, sanitary supplies, extra eyeglasses), a change of clothing, as well as diversionary recreational equipment for children and adults (for example, crossword puzzles, card games, drawing materials, and toys) are helpful (FEMA, 2003; Hayes et al., 1990).

Items for First Aid Kit (Federal Emergency Management Agency (FEMA))

flO**01

Ipf

first-ai

trauma

though

ph»tic

most I situati Ev< deveU tnemk Me in ferent ШШЄС attem alrea< items

EnBA

W<FuTB •M

m<

D

Aspirin or nonaspirin pain reliever, adult and child formulas Antibiotic ointment Antacid (low sodium) tablets

Cleansing agents (isopropyl alcohol, hydrogen peroxide)/soap/germicide Eye wash First-aid manual

Antidiarrheal agent (e.g., Kaopectate) Laxative Emetic agent (e.g., Ipecac) Activated charcoal (for use if advised by Poison Control Center) Cleansing agent/bar of soap Moistened towelettes Gauze pads, assorted sizes Gauze rolls Adhesive tape Adhesive bandages Latex gloves Lubricant (e.g., petroleum jelly) Triangular bandages Scissors Tweezers Sewing needle and thread Safety razor blades Safety pins assorted sizes Thermometer Tongue blades Sunscreen

FAMILY DISASTER PLAN [Federal Emergency Management Agency (FEMA)] Children know how to dial 911 Emergency phone numbers posted by phone

How and where to turn off utilities How to escape and where to go Where to meet with family members In case of separation (e.g., a neighbor's house or

across the street from the front door) Establish point of contact outside immediate area in case of family separation Plans for care of pets (pets are not allowed in shelters) Safety precautions for various kinds of disasters (e.g., fire, hurricane, etc.) Practice and maintain plan A list of necessary items in the event of a disaster.

The items on this list might Include medications, dentures, or eyeglasses; special food or infant formula; sturdy shoes and clothing for cold or inclement weather; identification; checkbook, credit cards, driver's license, and other important papers; money in low-denomination bills and coins; blankets; favorite toys and extra clothing for children.

Emergency Response

During the impact phase of a disaster, nurses and other emergency personnel are usually advised to remain in place until the situation has stabilized before attempting to provide care. In weather-related or predictable disasters, such as hurricanes or tornadoes, emergency personnel

might be asked to evacuate the site of the pending disaster as a safeguard so that they can render assistance after the disaster has struck.

Personal Concerns for Health Care Providers:

Evacuation out of the danger area might be difficult for health care personnel. Many are torn between their duty and the real need to remain with family members. Having a personal disaster plan with advance arrangements for family members helps reduce anxiety. Health care organizations need to consider the personal needs of their personnel when developing disaster response plans. Child care and family shelter should be part of the plan. Alternative transportation and modes of communication are essential. In certain circumstances, such as floods, earthquakes, and snowstorms, health care personnel might not be able to report to their assigned post on their own. If telephone service is interrupted, telephones and beepers might not function. It is important to include the local radio stations, ham radio operators, and telephone company representatives to assist in developing a realistic communication plan for the organization to allow for optimum communication between the organization, its personnel, and other community organizations during a disaster event.

Survey Assessments:

After a severe disaster, survey teams are assigned to make a rapid assessment of the casualties and damage to infrastructure. Health personnel are assigned to survey teams, and often community health nurses function as health-assessment personnel. Nurses who function on assessment teams are expected to perform casualty damage assessments, not render immediate first aid. This might also be problematic for some community health nurses, whose first instinct will be to render immediate care. The information obtained from survey assessments is crucial to help the EOC determine the emergency needs and plan for the appropriate equipment and personnel needs.

Dete rmin ing Immed iacy o f Care :

In a shelter or emergency aid station, planning focuses on establishing the priority of care need (triage), and deciding whether care can be provided at the station or only at an acute care hospital. Discharge planning begins when a victim enters the shelter or aid station. If victims are transferred to a regular community health care facility, the nurse needs to determine medical follow-up as needed in the community. Plans must also be made to deal with dead victims, notify and provide grief counseling for families, and arrange for burial.

Role a t Emergency A id S ta t i ons :

According to the ARC Disaster Services regulations, at least one registered nurse must be present while the emergency aid station is open. The ARC (1989) defines the functions of the disaster health service nurse in charge as follows:

¶ Arranging with the volunteer medical consultant for initial and daily health checks based on the health needs of shelter residents

¶ Establishing nursing care priorities and planning for health care supervision¶ Planning for appropriate transfer of clients to community health care facilities as necessary

¶ Evaluating health care needs¶ Arranging for secure storage of supplies, equipment, records, and medications and

periodically checking to see whether material goods must be ordered¶ Requesting and assigning volunteer staff to appropriate duties and providing on-the-job

training and supervision¶ Consulting with the shelter manager on the health status of residents and workers and

identifying potential problems and trends¶ Consulting with the food supervisor regarding the preparation and distribution of special

diets, including infant formulas¶ Planning and recommending adequate staff and facilities when local health departments

initiate an immunization program for shelter residents¶ Establishing lines of communication with the health-service officer¶ Arranging with the mass-care supervisor for the purchase and replacement of essential

prescriptions for persons in the shelter

Major Hea l th Concerns a f t e r a D i sas t e r :

After a major disaster producing severe disruption of community services and dislocation of citizens, a number of health- related concerns are present. Some of these can be anticipated and addressed in pre-disaster planning. In addition, any major disruption can expect to have repercussions that have health- related consequences, including potential overcrowding in shelters and other types of community-living arrangements, decreased personal hygiene and sanitation because of reduced services and privacy, increased personal injuries and malnutrition, potential contamination of food and water supplies, and disruption of public health services. Nurses working with a community disrupted by disaster can anticipate these types of problems and plan to reduce the health hazards associated with them via activating community resources, ensuring adequate sanitation facilities and on-the-spot health education to reduce health and sanitation hazards, initiating immunization programs to reduce the spread of communicable diseases, and overseeing nutritional and hydration programs to ensure adequate minimum standards for the population under care. During disaster situations, nurses must help individuals make the most of their health care, help maximize the populations' health, and find ways to improve the environment.

Psycho log i ca l Needs o f V i c t ims :

Disasters produce physical, social, and psychological consequences that are exhibited to various degrees in different people, families, communities, and cultures depending on past experiences, coping skills, and the scope and nature of the disaster (see Table 21-3). Health effects can linger for long periods, as noted after September 11 (Ferri, 2002). Because most people affected by a disaster pass through predictable stages of psychological response, nurses and other health care professionals can anticipate and prepare for the needs of the victims. The following victims of a disaster are more likely to need crisis intervention than others:

• Those who have lost one or more family members

• Those who have suffered serious injury

• Those who have a history of a psychiatric disorder

• Those who have lost their home or possessions

• Those who have been previously institutionalized for a mental illness

• Those who have suffered a pre-disaster stress

• Those who are poor or on a fixed income

• Elderly individuals

• Members of minority groups

• Those who have not handled previous crises in a healthy way, especially those who have been hostile or self-destructive during a previous crisis

• Those without adequate support systems

Most victims will have some psychological reaction to the disaster situation. These reactions are usually transient, and many victims recover on their own with support from volunteer workers and family members. The most important thing emergency personnel can do for victims is to recognize that they have a legitimate reason for their reactions and emotions and to work toward providing them with emotional support. A psychological assessment by the nurse will aid in identifying those individuals more prone to severe psychological distress.

It is critical that each survivor of a disaster be assessed for the level of psychological stress she or he is suffering and the degree of impairment she or he is experiencing in physical and emotional health and productive functioning. Individuals suffering minimal distress usually need support only from family and friends. Those who suffer a moderate amount of distress usually need the help of a support group or short-term counseling. Persons with severe distress might need extensive therapy. At the disaster site or primary triage point, simple support measures can alleviate the psychological trauma experienced by survivors. These measures include the following:

¶ Keeping families together, especially children and parents¶ Assigning a companion to frightened or injured victims or placing victims in groups where

they can help each other¶ Giving survivors tasks to do to keep them busy and reduce trauma to their self-esteem¶ Providing adequate shelter, food, and rest¶ Establishing and maintaining a communication network to reduce rumors¶ Encouraging individuals to share their feelings and support each other¶ Isolating victims who demonstrate hysterical or panic behavior

Some persons will need more intensive support. Whenever possible, community mental health nurses will be an important asset to the health care team to assist in meeting the psychosocial needs of victims. A quick psychological assessment guide is a useful tool to help emergency personnel determine the psychological state of victims, Individuals at risk for suffering psychological crisis after disaster might not seek help, even if they need it. Therefore, i t is essential that the nurse assess the stress level of victims, make other rescue team members aware of this, and refer those victims who need help from appropriate professional counselors. The nurse, as a member of the disaster team, participates in rescue operations and acts as a case finder for persons suffering psychological stress, intervening to help the victim deal effectively with the stress.

A research study of residents in Manhattan conducted after 5 to 8 weeks following the September 11, 2001, terrorist attacks found there was a high risk for depression and posttraumatic stress disorder (PTSD) among this population (Galea et al., 2002).

Recovery

During the recovery phase of a disaster, nurses are involved in efforts to restore the community to normal. Referral of injured victims tor rehabilitation and convalescence is important to reduce the chances of long-term disability; ongoing psychosocial needs must be addressed. Victims need to be linked with support agencies to help with food, clothing, shelter, and long- term counseling needs. Depending on the extent of damage to the community and the injuries of victims, the recovery phase can be relatively quick or can extend over a long period of time. Community recovery from the Los Angeles fires of 2003 is expected to take years. The San Francisco area has still not completely recovered from the earthquake of 1989.

It is very important for all emergency response personnel to learn from each disaster to improve response to the next emergency situation. For this reason, evaluation is an essential element of any disaster plan. Evaluation should include assessment of the effectiveness of the immediate response.

Personal Response of Care Providers to Disaster

Disaster workers are often overlooked when those affected by a disaster are considered. Health care workers are subject to the same concerns and emotional traumas as other community residents. Many disaster workers report being overwhelmed by the devastation and the extent of personal injuries. They might feel unqualified to cope with some of the medical emergencies presented. In major disasters, many work without relief for 24 to 36 hours. If they are residents of the affected community, they must deal with personal losses and concerns for friends and relatives in addition to working with the people under their care.

Responders can become stressed because their work environment is understaffed. They might be overwhelmed for days or even weeks after a disaster. As they reflect on the event, emergency personnel might second guess their actions and question their competency (Landersman, 2001). They might "burn out" on the job, becoming detached or over-involved. Chubon (1992) examined the responses of community health nurses during the aftermath of Hurricane Hugo in 1989. She reports that the nurses experienced conflict between family and work-related responsibilities. Many expressed feelings of anger, grief, and frustration about their personal losses. Supportive colleagues eased the stress for health care workers. The ARC encourages disaster workers to go through a debriefing process after their disaster work is complete. This process might consist of one or several sessions and is designed to help health care workers recognize and deal with the personal impact of the disaster.

NURSES’ ROLES IN DISASTERS

Determine magnitude of the event Define health needs of the affected groups Establish priorities and objectives Identify actual and potential public health problems

Determine resources needed to respond to the needs identified Collaborate with other professional disciplines, governmental and non-governmental agencies Maintain a unified chain of command Communication Nursing organizations must have a comprehensive and accurate registry for all members Have a structured plan:

Collaborate and coordinate with local authorities Have a hotline 24x7 Inform nurses where to report and how (keep records) Make sure have a coordinator to prevent chaos Ensure ways to maintain communication between nurses and their families

TOPICS THAT MUST BE COVERED BY DISASTER NURSING TRAINING (WHO, 2006) Basic life support System and planning for settings where nurses work Communications (what to report and to whom) Working in the damaged facilities and with damaged equipment Safety of clients and practitioners Working within a team (understand each member’s role and responsibility) Infection control Mental and psychosocial support

There are no laws specifically defining the scope of practice for nurses during a disaster. However, there are guideline sources, including a state's Nurse Practice Act, professional organization standards, a state attorney's opinions, and current and common practice laws. All nurses should be familiar with the Nurse Practice Act in the state where they live and work, not only for disaster purposes but also for the general practice of nursing.

SUPERCOURSE INITIATIVE

Super course is a “Library of Lectures” to empower educators.Twenty Nobel Prize winners, 60 IOM members and other top people contributed lectures. Gil Omenn, AAAS former president, Vint Cerf, the father of the Internet, Elias Zerhouni, head of NIH, etc. , Ala Alwan, Assistant Director General of the WHOWith the growing number of nurses in the network, there was a need to establish a Disaster Nursing Super course to emphasize the contribution of nursing to global healthHow:

¶ Provide training for future generations of nurses who might be engaged in a disaster¶ Collaborate with WHO¶ Build disaster nursing lectures to train nurses worldwide¶ Promote partnerships among instructors at schools of nursing in the world in the area of

disaster nursing¶ Offer up to date evidence based scientific knowledge to enhance faculty training

To join the Nursing Super course, please visit www.pitt.edu/~super1 Membership in the Global Health Network Supercourse will allow you to receive free Super course CDs, just in time lecture, and annual prevention lectures.

Bibliography Park, K., (2009). Park’s text book of preventive and social medicine, (20th ed.) Jabalpur:

Banarsidas bhanot publishers, 700- 707. Maurer, F A., & Smith, C M., Community/ public health nursing practice- health for

families and populations, (3rd ed.) New York: Elsevier publishers, 496- 512. http://www.pitt.edu/~super1/lecture/lec35051/index.htm http://www.ehow.com/about_4571887_disaster-nursing.html#ixzz24TivwkFB

Langan, J.C.,& James, D.C.,(2005).Preparing nurses for disaster management. New Jersey: Pearson education Ltd, 107-110, 40- 45