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Effective help to psychologically traumatized disaster victims require medical and psychological knowledge and understanding about normal psychological course and pathologic conditions that occur after a psychological trauma, which turns their lives into turmoil and subsequent stress. All those involved in the situation of critical injuries (the patient, close ones, bystanders, health professionals) respond in some way to the stresses inherent in such an emergency or disaster. Good self-awareness and emphatic ability are of great importance for adequate assessment of disaster victims, and to help victims and their families or close ones identify resources and implement coping strategies.
A crisis generally consists of three phases: a precrises phase, impact of the crises, and the postcrisis phase. Nurses and other responders intervene in all these phases by teaching patients, families, friends, and colleagues to avoid injury, helping at the trauma scene, and counseling or referring for recovery. Treatment of serious physical injuries has priority, but emotional support and psychological treatment should not be overlooked. Circumstances that elevate risk include bereavement, injuries, threat of life, separation from family (especially for youngsters), panic, horror, extensive loss of property, and relocation and displacement. The more exposures that people have experienced, the more likely they are to suffer psychological impairment (Norris, 2005).
The immediate psychological reactions function is to restore the feeling of having control over the situation and to strengthen the protection against the threat that the disaster result in. The reaction has in that way in the first phase a psychological, and sometimes even a physiological survival value.
A disaster is a situation that results in crisis because it is a sudden, unanticipated event that affects both the victim who experiences it and those concerned for that victim. Even large groups not directly affected by the disaster experiences crisis reactions. It is important at every larger accident to identify who has been affected, directly and indirectly. Among those affected by disasters are many people find:
In the situation of multiple casualties, such as a motor vehicle accident with several victims or a natural disaster (earthquake, tsunami, tornado), both victims and bystanders may react by becoming dazed, disorganized, or overwhelmed. The American Psychiatric Association has identified five categories of reactions in such circumstances:
The reactions of a given patient’s responses to life-threatening situations or injuries will be largely determined by the mechanisms that individual has developed over the years of dealing with stressful situations. Once the patient comes to view himself or herself as injured, a variety of common reactions occur: realistic fears, diffuse anxiety (feeling of helplessness and dependency), depression (psychologic response to loss), regression, denial, anger, and confusion (especially common among the elderly). In addition, every patient will feel some anxiety about undergoing a physical examination by a stranger, and should be shielded from the stares of curious bystanders; maintain conversation with the patient during the procedure.
Those at the scene may manifest many of the responses described above, and family members and friends may be anxious, panicky or angry (concerns and behaviors that arises from distress). Remain patient, sympathetic, and calm; explain to them what is being done and the reasons for various actions. Responders will also experience a multitude of feelings, for example, irritated at the demands, anxious in the face of a life-threatening situation, defensive at interferences they are not competent to handle a situation, and sadness in response to tragedy or disaster. An attitude of outward calm and confidence will do much to relieve the anxieties of others at the scene.
In mass casualties or disasters, treatment of serious physical injuries has priority but psychologic treatment should not be overlooked. The responders should identify themselves, keep spectators away from the victims, and assign tasks to bystanders. Accept each person’s right to have his or her own feelings and the casualty’s limitations as real (try to identify his or hers remaining strengths).
The needs of the responders are not to be overlooked after the injured is stabilized and the emergency phase has ended. Responders should have an opportunity to look back at their actions, consider whether to modify their interventions in the future, and reflect on their emotions after the rescue. A critical incidence debriefing for those involved in emergency response and interventions allow the team to consider the ethical issues involved in the rescue. The debriefing should occur as soon as possible after the event, with all team members present; otherwise inform team of the process followed, the discussion generated, and the recommendations made. The responders should be encouraged to contact the team leader if questions arise later.
Elisabeth Kubler-Ross (1974), a Swiss-American psychiatrist, identified the five stages of grieving that most persons go through when confronted with loss or potential loss:
The shock phase in the traumatic psychological crisis is short; a few seconds or minutes, up to hours, a few days or no more than one week. The reaction phase follow after the shock phase and can last a few weeks or months, sometimes up to one year. The change to the adaptation phase happens more successively than the change between the first and second phase. The adaptation phase is long; often many years at a strong psychological trauma. The phase of new orientation; succeed successively the adaptation phase and stays until the next time the individual develop a crisis reaction.
The most common traumatic stress symptoms include:
Sometimes can the threat or the external situation be so extreme that ordinary coping-mechanisms are totally useless, for example, the mass death and mass destruction in Hiroshima and Nagasaki, the German holocaust camps under World War II, the conditions of famine, long-lasting drought and in certain refugee camps.
Posttraumatic stress disorder (PTSD) is classified as a severe anxiety disorder that can develop after exposure to any psychologically traumatic event (sometimes months after). This syndrome was recognized as a diagnosis in 1980. Its features persist for longer than 30 days, which distinguishes it from the briefer acute stress disorder. The symptoms may not be evident until 3 months after the trauma, and maybe even years afterward. Posttraumatic is pertaining to any emotional, mental, or psychological consequences after a major injury, illness (HIV) or specific traumatic events, such as rape, crime and torture victims, witnessing murders or violent crimes, survivors of natural, technological or man-made disasters, military combat or terrorist attacks, workplace explosions, transport accidents, domestic violence and stalking, and hostage situations. The condition is defined as the state of an individual experiencing a sustained painful response to overwhelming traumatic events (a normal reaction to abnormal events; a traumatic stressor).
Critical defining characteristics include re-experience of the traumatic event, which may be identified in cognitive, affective, or sensory motor activities (flashbacks, intrusive thoughts, repetitive dreams or nightmares, arousal (difficulty falling or staying asleep), excessive verbalization of the traumatic event, or verbalization of survival guilt or guilt about behavior required by survival). Among minor defining characteristics is psychic or emotional numbness, such as impaired interpretation of reality, confusion, dissociation or amnesia, vagueness about the traumatic event, or constricted affect. Another characteristic is an altered life-style, characterized by self-destructiveness, including substance abuse, a suicide attempt, or other acting-out behavior; difficulty with interpersonal relationships; development of a phobia regarding the trauma; avoidance of stimuli associated with the trauma; poor impulse control or irritability; and explosiveness. PTSD may later present itself in the form of depression, substance abuse, somatic disorders or panic attacks, or physical symptoms, such as pain or irritable bowel symptoms. Trauma affects the whole being, mind and emotions, but also the body. The individual may exhibit signs of hyperventilation, irregular heart rate, shortness of breath, choking sensations, and confusion or inability to concentrate (American Psychiatric Association, 2000). Sleep problems are the most persistent PTSD symptoms. PTSD is considered a chronic condition if the duration is three months or more.
DSM-IV-TR specifies six diagnostic criteria for PTSD:
After a disaster event, assess and help the victim define the crisis, allow the victim to express feelings about the incident, explain hospital procedures, and provide emotional support. The DSM-IV-TR (the professional's diagnostic manual) classifies PTSD as an anxiety disorder. Anxiety disorders, symptoms onset after a post trauma event (American Psychiatric Association, 1994):
The least known and least appreciated characteristics of the anxiety disorders are depersonalization; the stripping of one's individuality and humanity, and entrapment; the sense that all escape routes from the trauma are extremely dangerous, costly, or nonexistent (Williams, Poijula, and Nurmi, 2002). Many individuals who suffer from PTSD remain unidentified and without adequate help.
The vivid visual imagery from the horrors of earthquake are apt to dominate the flashbacks and trauma re-minders by its victims, as well as Viet Nam War veterans had experienced relapses (by triggers) as a result of the September 11 tragedy. At high risk for PTSD are also fire fighters, police officers, rescue squad workers, and nursing personnel, who witnessed or experienced a traumatic or life-threatening event.
Most survivors will exhibit reactions to trauma, like anxiety, irritability, flashbacks, disbelief, hypervigilance, difficult sleeping, and nightmares. If the symptoms remain severe and impair the person’s functioning in 2 or 3 months, the person should seek help. There will also be people for whom the psychological symptoms will become permanent.
There are several psychological treatment programs of exposure therapy. In the event of a large-scale emergency, the American Nurses association (ANA) has drafted recommendations for nurses and other healthcare professionals to adopt when resources are scarce or care delivery occurs outside normal operating conditions (the ANA document is called “Adapting Standards of Care under Altered Conditions”). Nurses may be the first to identify and encourage those who have experienced overwhelming trauma to seek therapy by clinical specialists and nurse practitioners and build a network of safety and support.
The acute situation is in great extent affected by uncertainty. It can sometimes take many hours or several days before certain information can be given about the course of event, the causes of accident/disaster, who have been affected or the identification of killed. In wait of certain information, the close ones must be given a good human care, where the professional support is provided by human closeness, basic care and deep compassion. News of close ones death should never be given over the phone. Trauma survivors with PTSD have been treated with group therapy, individual psychological therapy, and support groups have also been helpful. The treatment goal of PTSD is to improve self-confidence and the sense of being able to cope with life, channel anger and manage stress, become more assertive and sense a control of their lives.
All nurses can help by listening intently, and tell them: When you're ready, I'm here to listen. Actions to facilitate communication under special circumstances are used, when patients are blind, deaf, or disabled or those who does not speak English. To learn some key phrases in other languages are valuable. Allow them to vent their feelings, and then restate the fact in simple language; it is all new to them. Learn cultural differences, the various cultural values of the diverse patient population. Expedite the reunion between the injured patients and their families and close ones. Refer the patient and his or her family to community resources and support groups as indicated.
To prioritize involves giving precedence to something or somebody. Treatment of life threatening acute injuries, and treatment of injuries that, if left untreated, will lead to permanent disability or premature death has priority. When new techniques and increased medical knowledge provided new possibilities for treatment, health care professionals were faced with questions about how and when they could be used. With increased knowledge and opportunities there was also a requirement that the patient should be more involved in the choice of treatment, and the requirement for informed consent arose. Limited resources have forced many countries to find ways of establishing priorities in health care. Making ethical decisions about disaster care is a complicated process for everyone involved, professionals and patients and/or close ones.
When a trauma victim sustains a fatal injury, it is sometimes possible to turn this tragedy (motor vehicle accident) into a gift of life for another patient. It is best to allow family or close ones a chance to grieve, express anger, and confront the tragedy of their loss before requesting organ donation. This process requires sensitivity as well as technical expertise. The donor's condition and care are always the first priority. Accept the family's decision to refuse tissue and organ donation (an intensely personal decision).