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Medical Support for Disaster Survivors (MSDS)
• Ali Menhem
• Amal Mazloum
2
Objectives
• Define Medical Support in the Time of Disaster• Identify the different types of disasters • Discuss the Mission Areas of Emergency Management• Provide overview of disaster plan development process• Discuss importance of WASH. • Vector control/pest management. • Food security/nutrition in disasters.• Shelter• Triage and Medical evacuation.• Infectious/Chronic Diseases and Disasters.• NGOs duties.• Team Work Communication.
Medical Support Definition
Medical support
Disaster
medicine
Disaster management
What is the Disaster
4
• “…a situation or event which overwhelms
local capacity, necessitating a request to a
national or international level for external
assistance.” (Center for Research on the
Epidemiology of Disasters-CRED)
• “…exceptional events which suddenly kill or
injure large numbers of people.” (Red
Cross/Red Crescent
• “…an occurrence that causes damage,
ecological disruption, loss of life, deterioration
of health and health services on a scale
sufficient to warrant an extraordinary response
from outside the affected community area”
(World Health Organization-WHO)
Disaster Types
• Natural
• Man-made‒ Accidental
‒ Malicious
5
TornadoNatural Disaster
ChernobylTechnological Disaster
Natural Disasters
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Man-Made Disasters
• Accidental‒ Factory Explosions
‒ Air or Sea disasters
‒ Fires
‒ Hazardous Material spills (HAZMAT)
• Malicious‒ Terrorist Activities
‒ Civil / Regional conflicts – WAR
‒ Embargos & Sanctions
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What do disasters affect?
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• People
• Places
• Things
Natural Disasters in Lebanon
.
Man Made Disasters in Lebanon
• Structural Collapse Terrorist Activities
• Fires
Disaster Impacts
Socio-economic
effects upon women:
↓ Protection
Behavioral effects upon
women:
↓ Resilience
Cultural effects upon community:
↑ Risk
Behavioral effects upon
potential abusers:
↑ Risk
Infrastructural Effects upon community:
↓ Support
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Emergency Management
Mission Areas
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PREVENTION PROTECTION
RESPONSE
RECOVERY
MITIGATION
Prevention/Protection
Response
Recovery
Mitigation
Post-EventEventPre-Event
Emergency Management
Mission Areas
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Steps in the Disaster Planning Process
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Responsibility for Plan Development
Emergency ManagerA big job but someone has to do it.
• Coordinate plans and preparedness activities
• Conduct vulnerability assessments
• Locate resources
• Establish mutual aid agreements
• Establish warning systems
• Plan evacuation routes
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• support for the emergency management program
• Develops Strategic Plan, Budget, and Status Reports
• Recruits Staff
• Liaison on Emergency Management Issues
• Enlist and train volunteers
• Educate the public
• Work with local government officials to establish mitigation actions
The Role of theEmergency Manager
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Session Rationale
33
A Hazards analysis and Risk
assessment process helps to answer
the following questions:• What does the community/Nation need
to prepare for?
• What resources are required in order to
be prepared?
• What actions (e.g., mitigation activities)
could be employed to lessen or eliminate
the threat or hazard?• What impacts need to be incorporated
into recovery preparedness planning? The results of the process form thefoundation for subsequent National Preparedness System activities.
Hazard Analysis Process
34
• Every community has an obligation to understand the
risks it faces.
• Risk is commonly thought of as a product of a threat or
hazard, the vulnerability of a community or facility to a
threat or hazard, and the resulting consequences that
may impact the community or facility.
• Knowledge of these risks allows a community to make
informed decisions about how to manage risk and
develop needed capabilities.
• By considering changes to these elements, a jurisdiction
can understand how to best manage risk exposure.
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These five steps are adaptable to the needs and
resources of any jurisdiction. The process can be
employed by a small, one-person department as
well as a larger organization with greater needs
and resources.
The 5 Step Process
Hazard Analysis
and Risk Assessment
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Orientation to Group Activity
WASH Standard
WASH: Water Supply, Sanitation, and Hygiene Promotion
Needs of the affected population are met and users are involved in the design, management and maintenance of the facilities
where appropriate.
Source: Bloland, CDC, Kibondo, TZ
1998
Source: Manya, Kenyan MoH, Dadaab, Kenya,
200637
Importance of WASH in Disasters
• More susceptible to morbidity/mortality
• Potential for epidemics and outbreaks of communicable disease
• Water, sanitation and hygiene interventions are primary means of prevention
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Importance of WASH in Disasters
• More susceptible to morbidity/mortality
• Potential for epidemics and outbreaks of communicable disease
• Water, sanitation and hygiene interventions are primary means of prevention
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Water Supply Objectives
Provide adequate quantity of safe water for drinking, washing, bathing, and cooking
• At least15 liters/person/day (5-7 liters minimum in acute phase)
Water should be easily accessible (distance, time)• Maximum distance of 500 meters • Maximum waiting time of 30 minutes
– 250 people/tap for flow of 7.5 liters/minute– 500 people/hand pump for flow of 17 liters/minute– 400 people/single-user open well for flow of 12.5 liters/minute
Adequate means to store water safely in home• Sufficient water storage containers for collection and
storage
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Water Supply
Access is as important as quantity!
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Types of Water Sources
• Surface water – lakes, streams, etc.– Easy to access
– Contaminated, may be difficult to treat
• Ground water - boreholes, wells– Access more difficult
– Quality better and easier to treat
• Other sources – springs, rainwater, bottled water, municipal tap water
• Tankered water – Expensive
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Water Quality Objectives
• Microbiological
– If NOT Chlorinated
• No fecal coliforms/100 mL
– If Chlorinated
• Turbidity less than 5 NTU
• pH < 8.5
• Free residual chlorine concentration 0.2 mg/L after 30 minutes of contact
• Chemical
– Arsenic, total dissolved solids, nitrates, etc
43
Water Quality: Where to Disinfect
• At source (wells, bucket chlorination, etc.)• At storage tank or bladder or tanker truck• At the household level
– Boil– Disinfection tablets (Aquatabs)– Chlorine stock solution– Flocculant/disinfectant sachet (PuR)– One Drop
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Drainage Standard
People have an environment in which health risks and other risks posed by water erosion and standing water (including storm-water,
floodwater, domestic wastewater and wastewater from medical facilities) are
minimized.
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Drainage
• Most effective way to control drainage is the CHOICE of SITE and the layout of the settlement
• Creation of small gardens to use wastewater
• On-site drainage preferable to off-site
• Where need off-site disposal, channels are preferable to pipes
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Excreta Disposal
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Fecal-Oral Transmitted Organisms
• Bacteria – cholera, shigella, E. coli, salmonella, campylobacter, etc.
• Viruses – GI viruses, Hepatitis A and E
• Parasites – giardia, cryptosporidium, amoeba
• Helminths – roundworm, hookworm, whipworm
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Excreta Disposal
• Correct design of latrines
– Pour flush vs. pit
– Squat vs. sit
– Separate stalls for females
• Lighting and other security measures
• Clean and well maintained!!
– Unhygienic latrines not used and can pose health risk
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Common Standards in Emergencies
• 20 people/latrine in stable phase (1 per family preferred)• 50 people/latrine in acute emergency phase
• Distance from water source = 30 m• Distance from shelter = 50 m or 1 minute walk (maximum)• Arranged by household• Separate toilets (men & women) available in public places• Bottom of pit is minimum of 1.5 meters above water table
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Sanitation in Public Areas
Institution Short term Long term
Schools 1/ 30 girls
1/ 60 boys
Same
Reception center 1/ 50 persons Same
Hospitals/clinics 1/ 20 beds or
1/ 50 outpatients
1/ 10 beds or
1/ 20 outpatients
Feeding centers 1/ 50 adults
1/ 20 children
1/ 20 adults
1/ 10 children
Markets 1/ 50 stalls 1/ 20 stalls
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Emergency Sanitation: Obstacles
• How to provide sufficient numbers quickly– Raw materials– Manpower, organization
• How to get people to use them– Cultural practices– Maintenance and cleaning
• Other obstacles– High water table or flood conditions – Hard soil conditions– Unstable soil– Lack of water for pour flush latrines
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Hygiene Promotion
• Targeting priority risks & behaviors– Prioritize assistance and misconceptions addressed
• Reaching all sections of population– Access & Awareness– Mass media– Different groups need different information (e.g. non-
literate, communication difficulties, no access to radio/tv)
• Interactive methods– Opportunity to plan/monitor own improvements, make
suggestions/complaints– Culturally appropriate
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Hygiene Promotion
Basic Hygiene Items
10-20 L capacity water container - transportation 1 / Household
10-20 L capacity water container - storage 1 / Household
250 g bathing soap 1 / Person / Month
200 g laundry soap 1 / Person / Month
Materials for menstrual hygiene 1 / Person
Example of Hygiene Kit
Possible Additional Items•Toothpaste•Toothbrush•Shampoo•Lotion (infants & children)•Disposable razor•Underwear (women & girls)•Hairbrush &/or comb•Nail clippers•Diapers & potties (depending on household need) 54
Key Indicators
Water quantity Liters/ person/ day
Access to water Distance to source, time collecting water
Water quality Chlorine residual or fecal coliforms
Sanitation Number of persons/ latrine (in use)
Access to sanitation Distance to latrines, male and female latrines
Hygiene Soap distribution or availability, water storage
vessels, hygiene promotion activities
WASH Summary Indicators
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Vector Control & Pest Management
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Contributing Factors
• Inadequate or absent housing
• Placement of camps near water
• Overcrowding
• Poor health, malnutrition, co-infections
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Pests vs. Vectors
• Pests do not transmit diseases, but are a nuisance that can affect moral (e.g. bed bugs, jigger fleas)
• Vectors transmit diseases that are a major cause of sickness & death in many disaster situations
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Environmental Control Measures
• Site Selection
– 1-2 km upwind from large breeding sites (e.g. swamps or lakes) when other clean water source can be provided
• Environmental/Chemical Control
– Proper disposal of excreta and refuse
– Drainage of standing water
– Clearing unwanted vegetation around open canals/ponds
– Spraying infected spaces
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Vectorborne Diseases
Vector Disease(s)
Mosquitoes Malaria, Yellow Fever, Dengue, hemorrhagic fever
Non-biting flies Diarrheal disease
Biting flies, bedbugs, fleas Nuisance, murine typhus, scabies, plague
Ticks Relapsing fever
Human body lice Typhus, relapsing fever
Rats, mice Leptospirosis, salmenellosis, can host fleas
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Malaria
• Estimated 225 million cases of malaria (2009)
– 781,000 deaths worldwide
– Decreases in burden in all WHO Regions BUT…….
• Fragile gains:
– Increased # malaria cases in three countries that previously reported reductions
• Endemic in 99 countries
Species Disease(s) Breeding sites
Culex Filariasis Stagnant water loaded with organic matter (e.g. latrines)
Anopheles Malaria, filariasis Relatively unpolluted surface water (e.g. puddles, slow-flowing streams, wells)
Aedes Yellow fever, dengue Water receptacles (e.g. bottles, buckets, tires)
Image from CDC Malaria Map Application
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Environmental Control Measures
• Site Selection
– 1-2 km upwind from large breeding sites (e.g. swamps or lakes) when other clean water source can be provided
• Environmental/Chemical Control
– Proper disposal of excreta and refuse
– Drainage of standing water
– Clearing unwanted vegetation around open canals/ponds
– Spraying infected spaces
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Chemical Control Measures
• National & international protocols
– WHO protocols/norms should be adhered to at all times
– Protocols for choice & application of chemicals including protection of personnel & training requirements
– Efficacy & safety
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Indoor Residual Spraying (IRS)Physical, Environmental, Chemical Protection
• Rapidly controls malaria transmission:– Need > 80% coverage
• Requires specialized spray equipment and techniques:– Must be maintained over
time
– Relatively expensive
• Increasing concern with insecticide resistance
Credit: Wirtz, CDC, Lugufu, TZ, 2006
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Personal Protection
All disaster-affected people have the knowledge and the means to protect
themselves from disease and nuisance vectors that are likely to cause a significant risk to
health or well-being
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Individual Protective Measures
• Awareness among affected people
• Avoid exposure (Bed nets, repellant, etc)
• Ensure bedding/clothing are aired & washed regularly
• All food stored in households is protected from vectors (flies, insects, rodents)
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Long Lasting Insecticidal Nets (LLINs)
• Offers individual level protection:– Community wide effect
if use is high enough (at least 60%)
– Must use correctly– Ownership ≠ use
• 2010 WHO recommends universal coverage :– 1 LLIN per 2 people
Credit: Williams, CDC, Mwange Camp, Zambia, 2009 67
Food Security
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Assessing Food & Nutrition
• Type, degree, and extent of food insecurity & malnutrition
• Determine those most affected
• Best response
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Assessing Food & Nutrition
• Type, degree, and extent of food insecurity & malnutrition
• Determine those most affected
• Best response
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Micronutrient Deficiency
Deficiency Potential Symptoms
Vitamin A deficiency Night blindnessBitots spotsCorneal Xerosis/ulceration/keratomalaciaCorneal scarsSerum retinol
Iodine deficiency GoiterMedian urinary iodine concentration (mg/l)
Iron deficiency Anemia
Thiamine deficiency (Beriberi) Anorexia/malaiseCardiac involvement with edema Peripheral neuropathy
Niacin deficiency (Pellagra) DermatitisDigestive tract and nervous system may be involvedAnxiety/depression
Vitamin C deficiency (Scurvy) HemorrhagesBone lesions
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Food Security
• Meet short-term needs
• Do no harm
• Reduce potentially damaging coping strategies (e.g. overuse of natural resources, travel to insecure areas)
• Restore longer-term food security
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Shelter, Settlement Management and Planning, Non-Food Items.
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Camps VersusIntegration in Community
• Advantages and disadvantages to both
• May be self-selection but not always
• May be mixture of camps and host communities
76
Camp Setting: What areadvantages and disadvantages?
Advantages• Services may be easier
to provide
• Easier to estimate population/numbers
• Advocacy
• Easier to monitor health status
Disadvantages
• Overcrowding may increase risk of disease
• Dependency of population
• Insecurity in camp
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Integration in Community: What are advantages and disadvantages?
Advantages
• Self sufficiency
• Access to work, farmland
• Use of existing services
Disadvantages
• Difficult to monitor needs
• Difficult to provide services
• May pose difficulties to host community
78
Coordination Between Camp LeadersAnd Organizations is Essential
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Shelter: Key Indicators
• For emergency measure, provide reinforced plastic sheeting, rope, fixings, poles, tools
• Adequate covered living area− 3.5 m2 per person
• Appropriate for climate− Heat (allow ventilation/avoid dry sun; double-
skinned roof)− Cold− Rain
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Non-Food Items: Generally
Principles
• Provision takes into account the climate, culture, and what people have carried with them from home
• Provision of local materials is optimal, but must consider impact on local population and environment
81
Non-Food Items: Specifically
Principles
• Sufficient clothing, blankets and bedding to provide protection from climate and to ensure comfort, dignity, health and well being
• Adequate items to prepare and store food, to cook, ear and drink
• Sufficient safe, fuel-efficient stove sand fuel or domestic energy, and artificial lighting to ensure personal safety
82
Non-Food Items
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Requires adequate storage facilities and distribution system
Non-Food Items: Types
• Separate clothing for women, girls, men and boys
• Blankets and bedding
• Insecticide-treated bed nets
• Cooking and eating utensils, water-storage vessels, cooking fuel
• Cooking fuel is particularly difficult to supply and may include firewood, charcoal– Stoves can provide warmth as well as cook
– Consider techniques/materials to improve fuel efficiency • Fuel efficient stoves
84
Non-Food Items: Key Indicators
• 2 sets of clothes, bedding, sleeping mats, and insecticide bed nets
• 2 family-sized cooking pots with handles, large basin, kitchen knife, and 2 serving spoons
• Plate, spoon or other eating utensil, drinking mug
• Fuel-efficient stove (changed from firewood)
• Tools for construction, maintenance, or debris removal
85
Casualty Management in the Field: Triage &
Hospital Levels of Care
Decisions may be based upon:
• Golden hour concept & Triage
• Evacuation procedures
• Hospital Treatment capabilities
Golden Hour Concept
• Golden Hour
– Advanced Life support as soon as possible, but not exceeding 1 hour.
– If surgery is required, it must be carried out as soon as possible, but not exceeding 2 hours.
87
What is Triage?
• Triage, derived from a French word meaning to sort, is the first step in the hierarchy of medical support at major incidents‒ Triage
‒ Treatment
‒ Transport
• Goals of Triage - not only to deliver the right patient to the right place, but also:‒ Do the most good for the most patients…
‒ Accepting that valuable medical resources should NOT be diverted to treating an irreversible condition
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Triage (sorting casualties)
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Urgent resuscitative interventions are required for survival. It is likely that
individuals will die within 2 hours or earlier without treatment.
Ie: Airway obstruction, shock, severe trauma.
Require early treatment, for example surgery, and patients should be evacuated
to a surgical facility within 6 hours of injury.
Ie: visceral injury, limb fractures, closed head injury, eye injury, burns.
Treatment can be deferred if there are other casualties requiring evacuation.
These patients are ambulatory and follow commands.
Ie: closed fractures, soft tissue injury, closed chest injury, maxillofacial injury
Minimal chance of survival, and if there is competition for limited medical
resources, such cases will have lower priority for evacuation and treatment.
Evacuation
•Two types of patient transfers:1) Casualty evacuation: site of injury to closed medical within one hour. May not have advanced medical training.
2) Medical evacuation: evacuation of a casualty between two medical facilities.
•Factors: Time, ground , air, weather, Balancing demand on medical resources (treatment capability of each hospital level and the available evacuation assets).
90
UN Levels of Care: Level 1
Level 1 medical facility• Immediate life-saving & resuscitation• 2 medical officers, 6 paramedics, 3 support staff• Able to treat 20 ambulatory, and hold 5 patients for 2 days.
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UN Medical Facility: Normally included within basic Level 1 capabilities are: routine sick call and the management of minor sick and injured personnel, as well as casualty collection from the point of injury/ wounding, limited triage; stabilization of casualties; preparation of casualties for evacuation to the next Level of medical capability or the appropriate Level of Medical Support Facility depending on the type and gravity of the injuries; limited inpatient services; advice on disease prevention, medical risk assessment and force protection within the Area of Responsibility. A Level 1 Medical Support Facility is the first level of medical care where a doctor/ physician is available
UN Levels of Care: Level 2
Level 2• Damage control surgery & Intensive care-resuscitation
• Basic imaging
• 57 personnel, 3-4 surgeries per day, and hospitalization for 10-20 for up to 7 days.
Basic Composition:
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2 Surgeons (general and ortho); 1 Anesthetist; 1 Internist; 1 General Physician; 1 Dentist; 2 Intensive care nurses; 19 Nurses/Paramedic; 1 Radiographer; 1 Laboratory tech
A Level 2 Medical Support Facility provides all Level 1 capabilities and, in addition, includes capabilities for: emergency surgery, life and limb saving surgery, post operative services and high dependency care, intensive care-resuscitation, and in–patient services; also basic imagistic services, laboratory, pharmaceutical, preventive medicine and dental services are provided; patient record maintenance and tracking of evacuated patients are also minimum capabilities required for a Level 2 Medical Support Facility
UN Levels of Care: Level 3
Level 3• Multidisciplinary surgery and Medicine
• 90 personnel
• 10 operations per day,
• Hospitalize up to 50 patients for up to 30 days.
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At this level all capabilities of a Level 1 and 2 Medical Support Facility are provided and, in addition, capabilities for: multi-disciplinary surgical services, specialist services and specialist diagnostic services, increased high dependency care capacity and extended intensive care services, specialist outpatient services, maxilo-facial surgery
UN Levels of Care: Level 4
Level 4
Definitive Care facility
96
Level 4 medical facilities are definitive care facilities provided outside of the mission area to provide all levels of care, including specialist services not otherwise available, rehabilitation and convalescence. Level 4 facilities are often commercially contracted or contracted under a LOA with a national government.
Other considerations
• Neurosurgical, Radiology support
• Blood products, and supplies.
• Weather, Roads, accessibility
• Language, cultural differences
• Number of patients already transported there.
• Availability of transport
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Battlefield Care
Role 1
Forward Surgical Care
Role 2
Deployed Hospitals
Role 3
Regional Evacuation Hub
Role 4
CASEVAC< 1 hour TACTICAL
MEDEVAC1-24 hours
STRATEGIC AE24-72 hours
Evacuation & Triage
• TRIAGE: – IMMEDIATE: Will die within 2 hours w/o treatment.
– URGENT: Need surgery within 6 hours
– DELAYED: Don’t require immediate care, can wait.
– EXPECTANT. Deceased / incompatible with situation.
• UN LEVEL – 1: Basic aid and stabilization. 2 Doc’s treat 20 /day.
– 2: Damage control surgery.
– 3: Hospital care.
– 4: Definitive hospital
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Mass Casualty and Triage Principles Objectives
• Review mass casualty principles
• Review triage principles
• Having a system in place
• Goals
100
Triage and Evacuation
101
INCIDENTSITE
1 - Immediate
CCS
2 - Urgent
3 - Delayed
4 - Expectant
DEAD
MEDEVACLoading
Point
ReceivingHospital
ReceivingHospital
ReceivingHospital
T4
T1
T2
Body holdingarea
Temporarymorgue
Media Communications Role
• Help Public Understand Immediate Risks
• Move People to Take Protective Actions
• Help Prevent Casualties
• Eliminate Confusion
• Support Overall Response Efforts
• Promote Confidence in Government’s Ability to Protect the Public
102
Infectious/Chronic Diseases and Disasters
• Infectious disease as public health disasters
• Infectious disease subsequent to public health disasters
• Handling of dead bodies
• Specific infectious diseases
• Considerations with chronic diseases
103
NGO Duties
• Health promotion
• Manage health crises
• Community social problems
• Environment
• Economic
• Infrastructure development
• Women’s issues
• Child welfare104
Team Work Communication
5 Components of Crew Resource Management include:
1) Communication
2) Decision-Making
3) Task Allocation
4) Teamwork
5) Situational Awareness
Effective team communication takes into account barriers and biases in order to successfully accomplish a task, safely and minimizing errors.
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