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Roles and intervention aspects for
Physiotherapists in supporting
persons with disabilities affected by
natural disasters .
Eric Weerts , PT
HANDICAP INTERNATIONAL
Emergency Response Division
1
AIMS OF THIS PRESENTATION
1.Learn to differentiate emergency intervention from other types of responses.
2.Become aware of the main principles of intervention in providing adapted rehabilitation services in emergencies
3.Recognize the main technical aspects of physical rehabilitation and emergency
4.Understand the practical elements of implementing rehabilitation in emergencies through examples
5.Consult and retain some technical resources that can be used in emergency contexts and rehabilition
6.Learn about networks, organisations and operators in the field of Physical Rehabilitation and Emergency
2
1.Learn to differentiate emergency intervention from other
types of responses
• Do You know activities and situation that
require different types of responses in
physical rehabilitation ?
• Possible factors that influence response ?
• What is proper to an aftermath of a disaster ?
3
Factors - key terms
• Shifting needs in short time and notice
• Adaptation of mainstream physical
rehabilitation principles
• Complexity of issues arising in the same time
and space
• Forecasts of needs to consider in short term
• Future footprint of needs to anticipate
4
Transition to Development / Back to previous situation
Post emergency/ Early Recovery
Acute emergency
Adapting response to the evolving needs of the affected populations
Extremely vulnerable persons
(incl.PwDs)
Vulnerable persons
General population
Basic & Specific needs
Focus on specific needs
t
Possible answers :
• Time frame of intervention
• Cause / Reason for intervention
• Context /economic environment
• Level of interest of public / donors / media
• Means – technology
• Risk factors that will compound possible deterioration of context
• ,………………
6
Introduction to disaster/emergency
settings
The types of disaster that could cause or impact disability/injury prevalence can include :
– Earthquakes
– Typhoons
– Landslides
– Floods
– Armed Conflict ,….
Due to natural phenomena and climate impact on living environments
� Armed conflict situations are more forgotten in the literature ,….
7
It differs from a non-disaster setting
by:
– Destruction of pre-existing facilities / infrastructure, including damage to health care facilities and reduced capacity of care
– Risk of outbreaks of diseases/ not common before the disaster onset
– Destruction of means of communication
– Weakened coordination , disorganization of the usual health and support systems
– Challenges in identification and treatment approach due to high number of cases in short term
– Emergence of complex rehabilitation issues in the long term
– Security/ sanitation , self protective context of working environment
8
Broad and General principles on
emergency intervention in rehab care
• Extrication in challenging environments of victims
• Triage and First care with limited resources
• Surgical/medical attention
• Early Functional Rehabilitation
• Psycho-social support for patient and family
• Planning long-term rehab reintegration in post
emergency setting
• Define the need for skills transfer to local staffing
9
Rational for Intervention on vulnerability
and physical rehabilitation
10
Situation and outlook towards basic care and needed long term follow as lifelong
assistance ( needed for these affections ) is compounded by the breakdown of health
services and community support system due to the conflict such as:
•insufficient availability of emergency care for injured
•absence of prevention measures to reduce complications and additional disability
•No availability of early and long term physical rehabilitation services
•overload on remaining care institutions
•lack of medical supplies/equipment for basic quality care
•diminishing numbers of qualified health staff in care settings
•continuous displacement of vulnerable persons weakening their health status further
•Psychological insecurity burden on family members and caregivers of
injured/vulnerable not able to cope with this situation of constant insecurity
In emergency setting the situation can
shift + or - through :
• Timely arrival of recovery teams / aid
• Coordinated extrication/ evacuation efforts – Success depends on effectiveness of coordination between
different actors, local and foreign ones on the emergency theatre
• Triage / identification and First care– Rapid identification of cases by trained providers
– Concentrate on potential survivors in some cases
– Appropriate referral to a centralized point of care that can manage physical disability properly
– Resilience of the human factor to cope with conflicting situations, difficult and ethical choices to be made.
11
Forecasts of proportion of disabled
injured could depend on :
• The time of onset of the disaster in the day span ( night or daytime )
• Use of weapons/ arms in type of conflict
• Type of infrastructure and construction material used in buildings
• Policy and means for preparedness in the country / region of the disaster
• Local practice on preparedness ‘’culture’’ for disasters / emergencies
• Responsiveness of recovery teams in extricating victims within a critical window of time , as well as managing them in the first days after injury
• Availability or not of specialized equipment at extrication/identification that can be lifesaving
�It is difficult to forecast but relation deaths – injured ( 3 times more ) can be indicative
12
This situation gets complex when:
• Available rescue and recovery resources are limited
• Prioirities need to be set for victims that have the best chance of survival
• Limited resources need to be spread and focused on the most pressing needs
• External supporting staff has difficulties in coping with what they experience as professionals in a disaster setting .
• Identified victims with disability need dedicated long -mid term attention as opposed to other victims of the same disaster/context
13
Uncertain future footprint of needs
and burden of disability and injury • Rehab professionals know that :
- The burden of care will be important in the long term for family members / caregivers and society in case of permanent injuries
• Therefore it is important to allocate resources in a timely and balanced way in order to
– Ensure best possible management at all stages of disability
– Prevent costly complications and unnecessary treatments by smooth cooperation between surgery, rehabilitation staff social workers ,…
– Ensure maximal community integration and participation of family /relatives and care assistants in the process of support
– Be aware that charity attention span for support to disabled victims is high at onset of disaster but extinguishes in the long term when it is more/equally needed ,…
14
For persons with previous conditions , their
challenges in disasters are
• Inaccessible evacuation
and shelter options
• Damage/loss of accessible
homes and equipment
• Loss of care
supports/family
• Loss of income
(agricultural or other)
• PTS after violence / injuryTyphoon Ketsana, Vietnam 2009
Photo courtesy Eric Weerts, Handicap
International
15
2.Main principles of intervention in providing adapted
rehabilitation services in emergencies
16
Overview main points and
principles
2.1 Situation Analysis and Team work
organisation
2.2. Upgrading knowledge and Curriculum use
2.3.Awareness Education tools for Patients and
Caregivers
50 Min
Analysis and team work
• Increase of involvement of rehabilitation professionals in the aftermath of disasters since the last years
• Need to have more specialised human resources on the field
• Need to adress the complexities of the disaster theatre
• Better scientific documentation that highlights the challenges of needed long term follow-up of disaster events
18
Field Principles in Physical and
Medical Rehabilitation • Interdisciplinary approach in emergency
context must start early as possible
• Coordination of care activities must be streamlined in team approach
• Local health and rehabilitation staff needs training in PM/concepts
• Anticipation of long term needs of severely injured must start as soon as possible in order to prevent disibilitating consequences
19
Field conditions to start up
Rehabilitation program in emergency
context • Logistics and security frame work is validated
• Set up of local partnership to operate in the best legal conditions possible
• Transport and acces to trauma care units with a clear mandate and visibility prepared by the organization
• Formulated terms of reference that describe the task required for the rehabilitation responder : technical / managerial level
20
Basic roles for team leaders
• To ‘’ cement ‘’ a vision among the different stakeholders on trauma care on the importance of global and long term approach towards early identified victims, to act as a link between surgical/acute and rehab teams
• To assess in depth the medical aspects of rehabilitation medicine that are required for implementing trauma care and rehabilitation in safe conditions.
• To provide direct technical assistance in constituting adapted protocols that allow physical rehabilitation programs to function optimally
22
Transfer of knowledge role
• To participate in training the rehab team and non rehab staff in the sound management of trauma victims leading to a comfortable setting to implement physical rehabilitation
• To assist directly in care techniques not known by the mainstream trauma team, provide clinical analysis and interpretation of observations , manage complex trauma cases
• To assist the team in the diagnosis of complicated cases and clarify diagnosis and non- detected conditions
24
Personal skills of team members
• A mindset and attitude that should be resilient
towards insecure working environment , need
for prioritizing personal security and
respecting operational and logistical
procedures .
• Being able to cope with varying workloads in
terms of patient numbers and be flexible in
the team approach
26
Team approach in physical
rehabilitation
• Ideally the PM/R should be team leader of the most common profiles Handicap International is working with :
- Physiotherapists
- Occupational therapists
- Social workers
- Psychologists
Although these profiles are not present at once in the timeline of projects ( 5 – 8 months ) , the team leader needs to ‘’ bridge ‘’ their absence by increasing of task sharing and coaching of the team
28
Conclusion
.Rehab team leaders are a key Human Resource in disaster setting.
.Their specific skills and know how should be placed within the available rehabilitation teams made up of physical therapists , occupational therapists , psychologists and nurses during an emergency.
.Special efforts should be done to identify the needed skills and allow these skills to be used on the field and the team setting beyond the pure medical standard of operations.
29
3. Upgrading knowledge and
Curriculum use :
Creation process of teaching materials for
upgrading Physical rehabilitation knowledge on the
Syria crisis intervention
30
Main objectives of training
intervention• Identification of needs among injured and
displaced population ( SCI and others )
• Provision of care and technical aids
• Training of Syrian Therapists and Rehabilitation workers
• Develop strategy elements for near future rehabilitation systems
31
Main features of the teaching materials
• Teaching materials seek to address the urgent needs of having in a short time training materials available for PT and Rehab workers .
• It includes as a first step short training sessions for Syrian physiotherapists and Health sector professionals (who will assist physiotherapists).
• This training material allows them to better deal with war-related injuries and/or disabilities in an emergency context.
• People who will attend to this training will be Syrian physiotherapists and or rehab workers graduated/ working in health structures (hospital, rehabilitation center…) in Syria.
• The training period takes place during five days with a maximum of 8 participants.
• Continuing education , activity sheets and technical supervision ensure follow up and quality control after this basic training
32
4 . Used ressources
PTA
MANUAL
Standard Contends PT/RW
Module 1: Methodology for rehabilitation cares and advices in emergency approach
Module 2: Rehabilitation assessment
Module 3: Rehabilitation cares and advices
Module 4: Mobility devices and specific items
Module 5: Prosthesis and orthotics
Module 6: Environment management (advices on accessibility)
Module 7: War injuries rehabilitation management
Module 8: Psychosocial approach
34
Additional features
Quizz to test knowledge
Powerpoints for delivery of teaching ( Arab/Eng)
Protocols of care for conditions
TOT module for team leaders / manager roles
Resources on web in arabic/ english
35
36
37
Protocol of care
38
39
Context of teaching and delivery
-Face to face teaching for PT / RW
-Teaching on distance for remote project
-Mix of both modalities
-Back up of rehabilitation supervisor to ensure
quality in practice delivery if needed according
project sites
40
Limits of curriculum
• Short cut of curriculum process
• Focused on contend and fast delivery
• Continuing education process does not follow
the needs of long term approach
• Roles of PT and PTA on the field
• Thin line between PT and RW in Syrian
education PT ,…
41
Early rehab protocol
• Destined for hospital PT
development
• Good shift between
emergency and long
term development
• Guide and reminder
tool for knowledge
upgrade
50 Min
Checklist knowledge
50 Min
Practical implementation kits for wheelchairs and
temporary prosthesis
• Emergency wheelchair
• Temporary prosthesis fitting
50 Min
Emergency wheelchair
50 Min
Characteristics
• Bright color for visibility
• Fast assembly ( ‘’ ikea ‘’ type )
• Accessories : cushion , basic maintenance
• Interchangable materials
• Life expectancy : 8 – 9 months in difficult
conditions
• Training of staff in 2 days
50 Min
Emergency Response Wheelchair
Training PackageDay 1
1230 Introduction and background to project
1300 1. Emergency wheelchair provision overview
1330 2. Emergency Response Product
1445 3. Eight Steps of Wheelchair Service
1515 BREAK
1530 4. Intro to Assessment/Prescription/Fitting form
1545 5. Assessment/Prescription/Fitting Skills
1630 6. Assessment/Prescription/Fitting Skills
1730 7. User training demonstration and practice
1830 FINISH
Day 2
0830 Review from Saturday/questions
0900 8. Rapid Response Wheelchair Service Set-Up
0945 BREAK
1000 Micro training sessions
1200 Feedback and discussion
1300 FINISH AND LUNCH
Wheelchair Service Levels
WH
O S
erv
ice
Le
ve
ls
Ba
sic
Users of manual wheelchairs without modifications
Inte
rme
dia
te
Users of manual wheelchairs with supportive seating
Ad
van
ced
Users of complex supportive seating and mobility equipment
Em
erg
en
cy
People in an emergency situation who need a wheelchair
immediately.
Selection of type of fitting
50 Min
Demo fitting process
50 Min
Principles - Recommendations
� Amputation usually means disability;
� In order to decrease as much as possible
the level of disability and to improve the
surgery’s outputs, medical services should
be accompanied with rehabilitation
services (Sphere Standards, WHO 2011
World Report on Disability);
� Input from rehabilitation should start pre-
operatively (level of amputation) and
follow-up should be provided until returning
home (social inclusion);
� Early rehabilitation and provisional
prosthetic services are possible, even in
emergency situation.
52
4. Education tools for Patients and Caregivers
• General principles for education tools :
- Use of basic language
- Easy to translate
- Use of visual designs
- Inquire about local culture and custom
regarding information spreading
50 Min
Information in pathology -
outcomes
• Contend should not be technical
• Do not use comparitive information regarding
outcome
• Do not refer to medical diagnosis – file
information regarding long term outcomes
• Be careful on advising further medical
treatments
50 Min
Examples information
50 Min
Should lead to advise
50 Min
Exercise programs
50 Min
Patient and family
information/education systemsDuring the aftermath of a disaster , this issue is one of the most critical ones due to :
-Need for early information provision on disability and injury status towards family and patient , ideally supervised as early as/when possible by a trained psychologist/social worker / counsellor understanding local culture and custom
-Coping of family and patient with aftermath of disaster in general ( affected communities , families ) as in particular ( change in routines/ life after injury )
-Need to understand promptly the crucial role of family / care attendant in the long term physical and social rehabilitation approach within local cultural context
-Need to have support from care attendants to relieve the ( limited ) health staff on the disaster/emergency theatre while safeguarding the quality of the care and avoiding complications ( ex: avoid unsafe log rolling and/or poor hygiene during handling , sustaining therapeutic exercise ,… )
59
Patient and family
information/education systems (cont)
Pamphlets need to :
– be as simple as possible with
• Few text
• Lots of images
– allow
• Fast translation in local language
• Easy understanding for illiterate persons
• Use comic strips for persons with limited illiteracy
• Give insight to local health staff not familiar (yet) with rehab management
60
Courtesy of F Stephenson
Types of interventions regarding
information and education (cont)
- Individual counselling ( early stage )
- Group education that allows sharing of ideas and
answers to questions
- facilitate linking with medical teams
� Provided by trained resource persons to
patients and their families
- Peer support ( later on )
–Issuance of practical dedicated information
–Giving Emotional and mentor support
� Provided by trained peers with life experience in
disability 61
Known practices during interventions
• Uphold the continuum from acute/surgical care /rehabilitation towards integration
• Cohort identified patients in designated physical rehabilitation sites with family support
• Initiate training/mentoring in under-resourced regions for short and long term goals
• Foster coordination of care between stakeholders of care in emergencies and long term development
• Ensure that patients carry their disability background information with them in the continum of care to avoid drop out of follow-up when moving to other places . Courtesy of F Stephenson
Interactive websites
• www.Physiotherapyexercises.com
• http://www.tbistafftraining.info/index.html
50 Min
5. International Resources
• International Professional networks have special
features on emergency – disability :
- International Society for Physical Medicine and
Rehabilitation
- World confederation of Physical Therapists
- World confederation of Occupational therapists
,…………………..
50 Min
International NGO – technical
thematics • MSF ; HI , CBM , Doctors of the World , IMC
• UK MED : UK International Emergency Trauma Register
(UKIETR)
• Handicap International UK is managing the PT
preparedness training
• http://medbox.org/ : resource site with available technical
documents
• http://www.rehabmonitor.org/ distance education resources
50 Min
Main guides
66
http://www.sphereproject.org/resources/download-publications
67
Side remarks
- Gives an overall view on minimum standards
- Describes the context in wich Rehab actors
have to work
- Is not rehab specific ( should be reviewed
- Broad base of editorial resources ( NGO ; IO ;
experts ,…)
- Is used as an international tool for goverments
and some UN agencies
68
Technical guidelines
• http://www.who.int/
hac/global_health_cl
uster/fmt_guidelines
_september2013.pdf
?ua=1
69
Main contends
70
Regarding physical rehabilitation
• Better need to
define PT services
• Needs additional
protocols for each
condition
• Work in progress (
WHO – international
organisations
• Helps to compare
capacities
• Readable standard
for international and
local actors
71
Disability checklist
72
Awareness tool for
73
Health
74
HI tool’s rational
• Broad awareness for
other humanitarian
actors not familiar
with Disability
• Teaching guide for
field workers
• Houses the issues of
physical disability in
health
75
Others
• Psycho social issues
• Protection of
children and women
• Accessibility
• Rights of victims of
disasters and
conflicts
• Issues that the actors
on rehab care might
be confronted with
76
Examples
77
Adapt to local needs
• Consider environments, resources, culture of the disables / injured persons
• Educate patient and family within local context and participation
• Assess/consider carefully unforeseen outside interventions
78Courtesy of F Stephenson
Conclusion on characteristics of
disability in emergency • Factors like time – context – nature of disaster – type
of conflict – shifting needs in short notice differentiateemergencies from development
• Guides and principles of emergency interventions provide basic classification of rehab activity in emergency management
• Physical rehabilitation , comprehensive approach on disability and capacity building need to be adaptedand refocused to be effective
• Disability factors of injured and prevention of permanent disability are not well known amonghumanitarian stakeholders . This needs to be more advocated .
79
Thank You
80