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Disasters are sudden catastrophic events that substantially damage property and harm people and animals. According to the American Public Health Association (American Public Health Association, 2005, 1) a disaster can be defined as an emergency of such severity and magnitude that the resultant combination of death, injuries, illness, and property damage cannot be effectively managed with routine procedures and resources. Life or death is usually in the hands of the nearest person, at the time of the disaster and before the arrival of professional help. The nature of the situation, population density and vulnerability, the response at the scene, the hazards involved, time "night or day", environment, and climate are of great importance. Need of care, and resources can vary, during the course of disasters.
Disasters encompass several unique problems not encountered in the routine practice, so planning and rehearsing for such events are essential. Examples include the need for warning and evacuation, widespread search and rescue, triage and casualty distribution information systems, communication, and extensive coordination. Recent disasters have demonstrated the urgent need for professionals, to be prepared, respond quickly, as well as function under extreme pressure. Therefore a disaster-preparedness plan, a formal plan for action, for coordinating the response (functions of care, communications, and resources) in the event of a large-scale accident or disaster is needed. When a disaster occurs, the first response will mobilize the emergency care system, fire fighters, police officers, and other identified responders. Hospitals, and other health care facilities will activate their disaster plans, and emergency operation centers will open. Disasters require international cooperation to prepare for and respond to attacks, events, outbreaks, or other large-scale disasters. A number of voluntary agencies such as the International Red Cross, Doctors Without Borders/Médecines Sans Frontières, Save the Children, and the Salvation Army will also respond.
Disasters for which there are prior warning such as slow-rising floods, tornados, hurricanes, and winter storms tend to have fewer injuries and deaths. While disasters with little or no advanced warning, such as earthquakes, tsunamis, and weapons of mass destruction/terrorism (WMD/T), will often have more casualties, since victims have little time to react or get away from the endangered area before the disaster strikes. The types of injuries and illnesses that occur will depend on the type and severity of disaster, timing, care, communications, and available resources. Disasters can be classified according to their speed of onset (sudden or slow), or according to their cause (natural, manmade or complex). Disasters can be both natural and man induced.
NATURAL DISASTERS AND SEVERE WEATHERS can be categorized as sudden or slow in their onset.
Flooding is the most frequently occurring of all natural disasters. Ninety percent of all hurricane-related deaths in the United States are due to storm surge, flooding, and drowning (Meredith, & Bradley, 2002). Tropical cyclones have differing names depending on the body of water in which they develop. These storms are referred to as hurricanes in the Caribbean, Golf of Mexico, and Pacific Ocean, as typhoons in the Northwest Pacific and Asia, severe cyclonic storms in the Bay of Bengali, and severe tropical cyclones in South India, the South Pacific, and Australia (Suthpen, 2006). People may be unaware of safe evacuation routes, and forced to leave their homes as a result of the disaster, usually in search of food, water and shelter.
MANMADE AND TECHNOLOGICAL DISASTERS, include a broad range of incidents and routes of exposure.
Communities in which industrial sites are located or through which hazardous materials pass are at risk for technological disasters. Transportation crashes may result in multiple patients with injuries ranging from minor to life threatening. Increased transportation by airplanes, huge ships, and rapid trains are leading to many injuries and deaths, and are requiring both time and resources at a maybe very risky, chaotic and remote disaster scene.
Bioterrorism agents (biological weapons, such as bacteria, viruses, vaccine, multidrug resistant organisms, and toxins) include smallpox, anthrax, botulism, cholera, plaque, tularemia, and hemorrhagic fevers (the Ebola and Marburg viruses).
Chemical emergencies include for example, benzene, chlorine, ricin, sarin, and sulfur mustard. The effects of chemical terrorism are usually immediate and obvious.
Radiation emergencies include dirty bombs, and nuclear blasts. Mass casualties may include explosion/blasts, burns, and severe injuries. Lung damage, skin disorders, and burns can result from exposure to specific agents.
The outbreak and spread of infectious diseases depends upon pre-existing levels of the disease, ecological changes resulting from disaster, population displacement, changes in density of population, interruption of basic public health services, disruption of public utilities, and compromises to sanitation and hygiene (American Public Health Association, 2005, 1).
In 1918-19 "Spanish Flu" killed over 20 to 40 million people worldwide (Lashley, 2006). This human influenza pandemic, as well as the 1957 "Asian flu", the 1968 "Hong Kong flu", and the 1977 "Russian flu" all evolved from viral strains that had initially demonstrated low pathogenecity for humans. Outbreaks of avian influenza (H5N1), and SARS (Severe Acute Respiratory Syndrome), require appropriate prevention and control measures, in an attempt to avert the spread of a possible pandemic. Early detection and surveillance of infectious disease outbreaks, vector control, safe water supply and food handling minimizes the opportunity for disease transmission. The 2009 flu pandemic was an outbreak of a new strain of H1N1 influenza virus, usually referred to as "swine flu". The Centers for Disease Control and Prevention (CDC) recommendation stated "emergency warning signs" and advised seeking immediate care if a person experiences any one of the listed signs. In severe cases, patients generally begin to deteriorate around three to five days after symptom onset.
Emergency wound management are common interventions in the disaster field. Resistant microorganisms, such as methicillin-resistant staphylococcus aureus (MRSA), and vancomycin-resistant enterococci (VRE), are now of great concern regarding infection control (Infectious Diseases Society of America, 2006). Gram-negative microorganisms, such as acinetobacter, enterobacter and klebsiella, are all showing increasing patterns of resistance.
The risk for injury during and after a disaster is high. Whether or not exposure occurs will depend on a populations exposure to a hazard (the event itself), and a community’s vulnerability, and capacity to respond. Risk assessment is used during the prevention and preparedness phases as a diagnostic and planning tool to determine how many excess cases of outcome (Risk of disaster = Hazard x Vulnerability - Capacity) (Shodell, 2006). A significant amount of injury also occurs during post-disaster cleanup. Survivors of disasters, and rescue squad workers, police officers, fire fighters and health care personnel who witnessed or experienced a traumatic or life-threatening event that has had the potential for bodily harm are also at high risk for post traumatic stress disorder (PTSD) (van der Kolk, van der Kolk, McFarlane, & Weisaeth, 1996; Gamper, Willeit, Sterz, et al., 2004).
Earthquakes, hurricanes, weather-related disasters, transportation accidents, industrial accidents, occupational accidents, and environmental disasters may result in multiple injuries and life-threatening conditions. For example, transportation accidents are the leading cause of death during winter storms (American Public Health Association, 2005, 1). Chronic health conditions (such as respiratory problems and cardiovascular disease) can be aggravated, and stress-related symptoms can also occur during a disaster and afterwards, as well as infectious disease outbreaks (such as pneumonia, diarrhea and cholera) commonly in the recovery phase (American Public Health Association, 2005, 1; Suthpen, 2006).
Terrorist attacks, are often totally unexpected and unpredictable. For example, in an unannounced attack, the detection and identification of the agents would not take place until after patients begin to present in the emergency department and physicians offices. Many health care providers lack clinical experience with most of the agents that could be used as weapons. If terrorists are using the unknown agents or are not limited to the use of a single agent, clusters of patients may present in the emergency room with similar symptoms, but different illnesses (Veenema, & Toke, 2006).
Risk factors for infectious diseases outbreaks include increase in disease vectors, overcrowding, disruption in water supplies and waste management systems, and interruption of public health programs and the healthcare infrastructure (Greenough, 2002). Under certain circumstances disasters can increase disease transmission, by fecal contamination or respiratory spread (Suthpen, 2006). Surveillance studies to carefully monitoring increased risk and changing trends for colonization with multi-drug-resistant pathogens, such as VRE, and health-associated, or community-acquired MRSA infection are mandatory.
Health care professionals can be prepared for disaster events by being aware of community hazards, warning systems, and vulnerabilities, as well as being familiar with the health care system and its level of preparedness. Healthcare professional should also be familiar with their employer's disaster plan, including their role in its execution. It is important to increase one's knowledge about disaster management especially in relation to bioterrorism, since nurses may be called upon to educate other people (Willshire, Hassmiller, & Wodicka, 2004). Numerous resources exist for health care professionals, fire fighters, police officers, and other responders who wish to become better prepared to respond to potential disasters and the challenge involved in the planning, implementation, operations management, and evaluation of a large-scale disaster response. The role of the health care professionals during a large-scale disaster is to minimize physical and psychological trauma in the victims, on site, during transportation and at health care facilities. The health care organization must also control the flow of patients as best possible between hospitals. Other tasks include psychosocial care of the injured and information to close ones, the general public and the media.
Disaster plans should be based on what people are likely to do, and must be flexible and easy to change due to the number of laws, organizations, populations, technology, hazards, resources, and personnel involved in disaster response (American Public Health Association, 2005, 2). Disaster plans must be acceptable and should be widely disseminated among all those involved and should also be exercised regularly. A regional plan will bring together the corresponding agencies, to initiate a joint coordination and situation assessment process of damage, injuries, deaths, and secondary threats, and establish communication channels for sharing information. Local contingency plans (at each hospital and in the primary care facility), serve as a basis for how to best utilize resources when the medical facilities are under heavy press, and also describe how the facility’s disaster medicine is organized in each unit to provide the best possible medical care. Local contingency plans are continuously updated and should be well known by staff. Disasters do not recognize national borders and require international cooperation to prepare for and respond to attacks, events, outbreaks, or other large-scale disasters.
Hurricanes are expected, we know about them several days ahead of time and also the areas that will be affected. They are not controllable once they happen, but they are predictable, and we can start to evacuate beforehand. The Saffir-Simpson Hurricane Scale divides hurricanes into 5 categories based on intensity (American Public Health Association, 2005, 1; Suthpen, 2006). Category 3, 4 and 5 hurricanes are considered major storms. For example, a category 5 with a storm surge of more than 18 feet requires a massive evacuation of all residences within 5-10 miles. The higher the category of hurricane and the more shallow the offshore region, the greater the storm surge, which is the most dangerous part of the hurricane (especially at high tide levels) (Suthpen, 2006). Poor countries have weak infrastructure, and poor people cannot afford to move to safer places.
On September 11, 2001 the terrorist attacks on the New York World Trade Center (WTC) in lower Manhattan, the Pentagon in Washington DC, and the thwarted attempt in Pennsylvania showed that the entire world is susceptible to an unpredictable large-scale disaster at any time (Gaudette, Schnitzer, George, & Briggs, 2002). After September 11, a manmade combat situation, many people feared for their own lives, as their sense of security was shattered. After the anthrax attacks in the US and in Europe in 2001, the EU Council launched measures to prepare for bioterrorism and to improve cooperation among the member states and the EU Commission in Brussels (Sundelius, & Gronvall, 2004).
Early detection and surveillance of infectious disease outbreaks are critical components of preparation for potential biological attacks, so that effective prophylactic treatment can be given in a timely manner and it minimizes the opportunity for transmission of the agent (Veenema, & Toke, 2006). Symptoms of many biological agents resemble those of flu (with an incubation period of the organism) and are not easy to detect. It is essential to identify the mode of transmission and clinical characteristics of biological agents, and to identify infection control methods to prevent disease transmission. Response plans, implementation of decontamination procedures, as well as ways to preparing, documenting, reporting, and responding to a bioterrorist attack needs extra skills and training. The organization and cooperation among responders are of great importance.
Top-priority dangerous bugs, drug-resistant microbes such as MRSA, Aspergillus (fungal infection), and VRE are especially dangerous because few or no new drugs are being developed to treat them. Many existing drugs have harsh side effects, are toxic or interact with other drugs, and resistance to them is growing (Infectious Diseases Society of America, 2006). The present level of preparedness for the next pandemic is also insufficient. Worldwide measures are needed to stockpile vaccines and antiviral medications and improve the ability of vaccine manufacturers to develop and produce new vaccines for unveiling an avian influenza pandemic or swine influenza pandemic. Contributing problems of concern are the ease and rapidity of global movement of both animals and humans, naural patterns of avian migration, illegal shipment of potentially infected birds and animals, as well as legal and illegal human transportation and emigration (Osterhaus, 2005).
It is vital to stay up-to-date on basic life-saving techniques and trauma support skills and participate in disaster training drills to help prepare for potential disasters, and to be able to respond as effectively as possible Your own emotions and distress may also have an impact at the time of a catastrophic disaster. Home, school, and work fire drills are an excellent safety measure, and a good way to prevent panic is to know what you are going to do before a fire, storm, or earthquake happens. Drills are used to improve planning and training is most effective when carried out on a multiorganizational, multidisciplinary, and multijurisdictional basis (American Public Health Association, 2005, 2).
Within the United States, the specialty of disaster medicine fulfils the requirements set for by Homeland Security Presidential Directives (HSPD), the National Response Plan (NRP), the National Incident Management System (NIMS), the National Resource Typing System (NRTS), and the NIMS Implementation Plan for Hospitals and Healthcare Facilities. The classification system, the National Resource Typing System provides a unified cross-agency, cross-jurisdictional means of classifying all disaster-related resources that are or could be used in response to a NRP/NIMS event, whether these resources are equipment or personnel.
During a disaster situation, communicators must decide: Which populations are the most important to reach? When?, and What? Information is the most critical to convey? What is most urgent, and what tasks can wait until later? (Chess, Calia, & O’Neill, 2004). During risk communication, phone calls, short message service (sms), e-mails, and faxes can overwhelm local, county, and state areas. Training of disaster preparedness and responses, including information and communication is vital. Disaster warning messages need to be clear, consistent, and specific about what people need to do before, during and after an event. Help people with information seeking, have additional information (educational materials) available within the community for culturally diverse audiences, and also a language translation guide.
Estimating time and size of a natural disaster or terror attack enables a forecast of the number of persons that will require immediate and ongoing medical attention over the days and/or weeks. Information from several sources, including data analyzed from previous hazards, is needed to predict the nature, frequency, and intensity, and the area(s) most likely to be affected, and also the onset time and duration of future events (American Public Health Association, 2005, 3).
The data collected through Emergency Information Systems (EIS) are used to make decisions about the services that are needed post-impact (American Public Health Association, 2005, 4). For example, if a hospital needs to bring nurses from home following an emergency, Geographic Information Systems (GIS) can provide information about transportation by identifying safe passageways. Coordination of established communication channels for sharing information is needed. Websites can be set up during disasters for those who wish to donate medical supplies, drugs, provide housing, food, transportation, or personal items that are needed at the time.
The terrorist attack in New York and Washington D.C. on September 11, 2001, the earthquake and tsunami in coastal South East Asia on December 26, 2004, and the hurricane Katrina’s devastation, at the end of August 2005, as well as outbreaks of the avian influenza, have all demonstrated that there are many complex functions that must be coordinated in order to respond rapidly and successfully. Many people around the world were founding out about these disasters via mass media and the Internet. Data processing and exchange of patient information will be particularly important in the post-impact and recovery stages (American Public Health Association, 2005, 4). Information resources and services include data collection related to rebuilding, and documentation of lessons learned. The ability to assimilate available information quickly and transform it to knowledge, and occasionally wisdom, may provide each responder with a lot of satisfaction (Gaudette, Schnitzer, George, & Briggs, 2002).
Other major natural disasters are the Cyclone Nargis that hit Burma on May 2, 2008, and the 7.9-magnitude earthquake that hit Sichuan Province, a mountainous region in Western China, on the afternoon of May 12, 2008, killing about 70,000 people and leaving over 18,000 missing. Over 15 million people lived in the affected area, including almost 4 million in the city of Chengdu. The cyclone Nargis, the worst natural disaster in Burma's history, killed an estimated 140,000 people and left hundreds of thousands homeless and in desperate need of clean water and food. A massive earthquake struck Haiti on January 12, 2010, leveling Haiti's capital, Port-au-Prince. According to official estimates, 222,570 people were killed, 300,000 injured, 1.3 million displaced. February 27, 2010, one of the world's most powerful earthquakes in a century battered the city Concepcion in Chile, killing at least 214 people, knocking down buildings and triggering a tsunami that threatened Pacific coastlines as far away as Hawaii and Russia.
The recent Mammoth storm on February 1, 2011 hit the Eastern US, from New Mexico to Maine, roads were closed, and more than 10,000 flights canceled. A combination of ice, snow and rain pushed much of the winter-cursed region to its breaking point. A 6.3-magnitude earthquake ripped through Christchurch, New Zealand, on February 21, 2011 causing multiple fatalities as it toppled buildings onto buses, buckled streets and damaged cathedrals. On March 11, 2011 an earthquake with a magnitude of 9.0 hit northern Japan, triggering tsunamis that caused widespread devastation and crippled nuclear power plants in the Fukushima Prefecture. In the wake of Japans nuclear disaster, vegetables near the quake-stricken Fukushima Daiichi nuclear power plant show radiation, and also contaminated sea water.
The 7 July 2005 London bombings (referred to often as 7/7) were a series of coordinated suicide attacks upon Londoners using the public transportation system during the morning "rush hour". The explosions were caused by homemade, organic peroxide-based devices packed into the four militants’ rucksacks. Fifty-six people, including the four bombers, were killed by the attacks, and about 700 were injured. January 2011 protests, demonstrations and riots are erupting across North Africa and the Middle East in places like Tunisia, Algeria, Egypt, Oman, Yemen, Bahrain, Jordan, Albania, Syria, Lebanon, and Libya. Civil unrest has erupted in many countries, some of which have been under authoritarian rule for decades, all over the Middle East and North Africa. The United States’ costs related to the military intervention in Libya are in the hundreds of millions of dollars.
The 2009 flu pandemic was an outbreak of a new strain of H1N1 influenza virus, usually referred to as "swine flu". The Centers for Disease Control and Prevention’s (CDC’s) recommendation about who should receive annual seasonal flu vaccines is continuously updated. Both seasonal and H1N1 swine flu continue to infect us in 2010-2011, despite the fact that many believe that there is not much flu activity.