Understanding

UNIT 1 UNDERSTANDING DISASTER Disaster Medicine

MEDICINE
Structure
1.0 Learning Outcome
1.1 Introduction
1.2 Disaster Medicine: Meaning and Importance
1.3 Components of Disaster Medicine
1.3.1 Prevention
1.3.2 Preparedness
1.3.3 Response
1.3.4 Recovery
1.4 Post Disaster Review
1.5 Conclusion
1.6 References and Further Reading
1.7 Activity

1.0 LEARNING OUTCOME

After studying this Unit, you should be able to:

describe the meaning and significance of disaster medicine;

discuss the various components of disaster medicine; and

explain the medical and health management of disasters in the pre, during
and post disaster scenario.

1.1 INTRODUCTION
Disaster causes disruption to the human, social, economic and ecological life of
the society. Its causes disruption, death, damage, destruction, disability, epidemic,
diversion of resources and immense burden to the exchequer. The Medical
Preparedness for Disasters, define disaster as a situation in which the need of
medical care exceeds the immediately available resources, and in which
extraordinary and coordinating measures are necessary, if normal quality
standards are to be maintained.
Every year natural disasters take a heavy toll on human lives and property. The
United Nations finds that in the past two decades nearly three million lives
have been lost, and nearly 800 million people have been affected by disasters.
Each year at least four cyclones of varying intensity hit parts of India’s nearly
6,000 km long coastline, earthquakes of varying magnitude rock India, and several
die of severe cold and heat wave in northern parts of the country. The latest
tsunami disaster of 26th December 2004 with its epicentre in Indonesia cut
across most of the nations of South East Asia and took a toll of over 300,000
human lives. India, off course, remains one of the worst affected countries in
this disaster.
Disasters bring in catastrophy. Some of the disasters like, cyclone, floods and
droughts can be fairly predicted whereas earthquakes, landslides, flash floods, 1
Disaster Medicine and tsunami often occur suddenly. Besides, mankind has also exposed itself to
certain self-made disasters, such as, riots, accidents, fires, industrial and
technological disasters, and ecological disasters. However, whatever the nature
and type of disasters, they cause immense injuries and losses to mankind.
Disaster management aim to prevent deaths, diseases and injuries emerging
from any kind of disaster.
Medical and health services play an important role in health management of
disasters. During emergencies – disasters – they do not remain unaffected or
continue to stand alone. Rather, they move to the affected areas to provide
immediate rescue and relief.
In this entire Course of Disaster Medicine, we will mainly focus on the impact
of disasters on medical and health services, and how they can be best managed
to reduce the number of mortalities and morbidities resulting from disasters. In
the present unit, we will discuss the various aspects related to the prevention,
preparedness, response and recovery of health management in disasters. To
begin with, we will discuss the meaning and significance of disaster medicine.

1.2 DISASTER MEDICINE: MEANING AND

IMPORTANCE
Disaster medicine deals with the public health management of disasters. It
addresses various issues, such as, casualty area management and hospital
management through various strategies and actions.
According to the Australian Journal of Disaster Medicine, disaster medicine
involves the modification and expansion of health and medical capabilities to
counter a situation, which has the potential to overwhelm the services in situation.
According to Gunn, disaster medicine is the study and collaborative application
of various health disciplines to the prevention, preparedness, response and
recovery, from the health problems arising from disaster. This must be achieved
in co-operation with agencies and disciplines involved in comprehensive disaster
management.
Thus, disaster medicine includes the prevention, preparedness, response, and
recovery aspects of health management in disasters with an aim to mitigate the
adverse consequences and reduce mortality and morbidity.
We will now discuss these components individually.

1.3 COMPONENTS OF DISASTER MEDICINE

There are four components of disaster medicine, namely, prevention,
preparedness, response, and recovery.

1.3.1 Prevention
Prevention entails the following measures:
1) Preparation of mitigation plans
Preparation of mitigation plans with the medical and health component is
necessary. This should include:

Involvement of medical and health professionals in planning. The Statement
2 on Disaster and Mass Casualty Management, underscores the importance
 of surgeons to provide leadership at the community, regional and national Understanding
levels in disasters, and hence, requires them to participate actively in the Disaster Medicine
multidisciplinary planning, triage, and medical management of mass
casualties following all disasters.

Training and skills of surgeons… especially suited for the logistical demands
and rapid decision making required by large casualty following both natural
and manmade disasters.
2) Prevention of health risk
The Australian Emergency Manual lays down the following measures for
preventing the health risk arising out of a disaster:

Research and epidemiological studies

Immunisation and vaccination

Proper food and nutrition

Maintenance of hygiene and sanitation

Adequate system of garbage disposal

Vector control

Well laid down system of education, training and simulation exercises

Mitigation plans

Media campaigns

Sustainable development

People’s involvement
3) Debriefing or psychological debriefing (PD)
Debriefing or psychological debriefing is considered as ‘a single-session semi-
structured crisis intervention designed to reduce and prevent unwanted
psychological sequelae following traumatic events by promoting emotional
processing through the ventilation and normalisation of reactions and preparation
for possible future experiences’. It is both–individual and group–intervention.
With the help of debriefing it is possible to evaluate the responses of the disaster
victims, relatives, and disaster workers. Its basic aim is to evaluate the responses
and reactions of the disasters victims and workers following a disaster. This
helps in developing suitable public health interventions and strategies.
PD is considered to be preventive as it helps in judging the feasibility of the
medical and health plan, examining the aptness of various procedures, scrutinising
the skills and knowledge of responders, and also seeing through the ways that
went wrong and why, and how they can be improved for future.
PD has played an important role in minimising trauma in the recent Tsunami
and Gujarat earthquakes.

1.3.2 Preparedness
Medical preparedness, according to the Medical Preparedness for Disasters,
implies local reinforcement of important medical care functions. It is invoked
when available capacity is or can be expected to be insufficient for emergency
care. Medical preparedness basically implies planning for medical and health
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Disaster Medicine related aspects for meeting disasters. With disasters there is too much load on
the existing resources that one needs to remain prepared for the mobilisation of
the additional resources. In a situation when sometimes services are also required
from outside, preparation involves a lot more careful planning…. As the Journal
of Postgraduate Medicine stresses that a successful medical response to
multi-injury civilian disasters, …dictates formulation, dissemination and periodic
assessment of a contingency plan to facilitate the triage and treatment of victims
of the disaster. We need to develop such a plan in order to accurately assess
the magnitude of the disaster, and make provision for sufficient trained personnel
and logistic support to meet the demand of the mass disaster. Hence, planning
becomes the first and foremost priority in medical preparedness for disasters.

Medical preparedness planning involves the following:

1) Formulation of medical plan

Medical plan has to be prepared for three stages, namely, the pre-hospital stage,
hospital stage, and rehabilitation stage.

Pre-hospital stage

At the pre-hospital stage, the medical plan entails the organisation of medical
care at the site of disasters so as to make the care available to the victims as
soon as possible. For the pre-hospital stage the plan will include:

Setting up of emergency control centres

Setting up of command post in the disaster area.

Site assessment

Evacuation/casualty clearing teams

Site medical teams for first aid and resuscitation

Triage

Tagging

Mobile hospitals units for areas where medical care facilities are lacking,
and in places where the number of victims exceed the capacity of the
state.

Communication between the various field teams, command post and the
hospital.

Hospital stage

In the hospital stage, the preparedness plan will revolve round the management
of the casualties in the hospital. A committee comprising of the representatives
of the medical and para medics will prepare the plan. The plan will be based on
trigger mechanism, which will set the entire ball rolling at the very strike of
disaster. The plan will provide for:

Job description, check lists, and standard operating procedures for the staff.

Resources in terms of manpower, logistics, and finances to meet an

emergency.

A disaster manual for ready reference and made available to all.

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Coordination, supervision, control, and effective communication. Understanding
Disaster Medicine

Adequate number of ambulances for quick transportation of victims from
disaster site to hospitals.

Training, exercises, and drills for staff.

Food and stay arrangements for staff.

Security and protocol for visiting dignitaries.

Evacuation plan of hospital with which both the staff and the authorities
should be familiar. Temporary accommodation to the staff.

Temporary morgue facilities with relatives guidance cell.

Public relations system with a public relations officer providing accurate
information.

Dissemination and reappraisal of the plan in terms of the community’s and
hospital’s changing needs.
Rehabilitation stage
Rehabilitation stage will deal with the mental health rehabilitation of the disaster
victims.
The plan will focus on psychological interventions, which will address to the
people affected by psychiatric disorders, such as, acute stress disorder, post-
traumatic stress disorder, grief, anxiety and depressive disorders. The
intenventions will aim at strengthening of local resources, provision of information,
help people help themselves, establishment of support and information centres,
training in mental health to medical personnel, involvement of other sectors and
NGOs, debriefing of rescue workers, help to bereaved families, help to the
physically injured, help to the widows and orphans, preparation of a resource
guide or manual, and promotion of research on psychosocial subject.
2) Remote area planning
Planning for the far flung areas, i.e. the remote areas is required as these
areas have paucity of resources in terms of men, material, money and other
facilities such as hospitals, infrastructure, communication etc. However, these
days with health education, advanced technology, and community disaster
management plans at hand, it has become possible to overcome these limitations
to a greater extent.
Remote area planning is divided into two phases. The first phase aims at putting
the local resources at the disaster site immediately. The trained manpower has
to be sent to undertake the survey of the area, conduct triage, treat casualties,
and transport the affected. The second phase aims at sending the casualties to
the hospitals for treatment and specialist care.
Telemedicine can form an important part of remote area planning. Telemedicine
can help in catering to remote areas in disasters. With the help of telemedicine
it will become possible to render medical care and treatment to far off
destinations and locations. Telemedicine, according to Healthcare Management,
enables a physician or specialist at one site to deliver health care, diagnose
patients, give intra-operative assistance, provide therapy, or consult with another
physician or paramedical personnel at a remote site. This has greatest impact
in improving the quality, increasing the efficiency, and expanding the access of
the health care delivery system to the rural population at the time of disaster.
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Disaster Medicine The greatest difficulty of reaching to a remote site will be solved through
telemedicine as it offers connectivity with the urban areas. Further, it also enables
cost effectiveness, and timely feedback of the health problems in remote areas.
However, the initial capital investment for setting up V-sat connectivity between
the urban hospitals and the nodal centres in rural/coastal areas, need to be
supported by the government or the private sector.
3) Logistics planning
The hospitals and medical centres require additional logistics such as, clothing
and protective gadgets, casualty files, communication equipments, medical supplies
like medicine, gloves, machines, etc. during disasters. Hence, logistics planning
becomes important.
The basic principles of logistics planning are:

standardisation of supplies

utilisation of the locally available resources

assessment of the disaster specific needs of the affected community

proper planning of the resources from outside

inventory control system

efficient distribution system

adequate warehousing

efficient transportation system
4) Education and training
Medical preparedness plan should make provision for education and training
programmes in disaster management. The Statement of the American College
of Surgeons finds that disaster management poses challenges that are distinct
from normal surgical practice. It requires a paradigm change, from the application
of unlimited resources for the greatest good of each individual patient to the
allocation of limited resources for the greatest good of the greatest number of
casualties. This change is achieved most effectively by planning education and
training in disaster management.
The Statement highlights the need of education and training in:

Disaster planning and rehearsal

Integration of local, regional and national resources into a disaster
management system

Hospital emergency incident command systems

Communications and security

Media relations

Protection of health care delivery personnel and facilities

Detection and decontamination of biological, chemical and radiation exposure

Triage principles and implementation

Logistics of medical evaluation, stabilisation, disposition and treatment of
6 victims

Record keeping Understanding
Disaster Medicine

Post disaster debriefing, critique and reporting

Critical incident stress management

Published research and experience in disaster management.

It is incumbent upon all surgeons to attain an appropriate level of education and

training in the unique principles and practice of disaster and mass casualty
management. For the health programmes to be effective, education and training
should be a continuous activity with a focus on both immediate and long-term
strategies. The immediate term approach seeks to inform, update and motivate
the community in action. It focuses on immediate strengthening of individuals to
cope with a crisis in an organised manner. The long-term strategy focuses on
bringing attitudinal changes in the younger generation. It seeks to develop a
pattern of behaviour at an impressionable age for the long-term benefit of the
community.

There are many educational and training institutes that run disaster based
educational and training programmes, namely:

National Centre for Disaster Management, New Delhi

Disaster Management Institute, Bhopal

National Civil Defence College, Nagpur

Indira Gandhi National Open University, New Delhi

Centre for Disaster Management, Pune

5) Epidemiological study of disasters

Preparedness plan should focus on the epidemiological study of disasters.

Epidemiology, according to Eric Noji, is significant to decide the determinants
and distribution of health problems in the population of a particular place at a
particular time. This will help in measuring and describing the consequences of
the natural and man-made disasters on health. With the help of epidemiological
methods, it is possible to gauge the needs of populations affected by disaster,
relate the resources to their needs, check the adverse effects, review the efficacy
of various health programmes, and prepare better plans for the future. Strategies
can be adopted to lessen morbidity and mortality in future by identifying risk
factors, planning the warning and evacuation system, developing guidelines,
enhancing education and training programmes, generating public awareness and
preparedness, anticipating future health consequences of disasters, and data
collection and analysis for taking short term and long term decisions.

6) Networking

Preparedness plan should give importance to joint working and networking of

all those who are involved in rescue and relief operations. Such collaboration
should also involve the people who are affected by disaster.

7) Media

The most important factor to be taken care of is that the disaster events should
not be hyped or sensationalised. Media should give timely information about
disasters, do’s and don’ts, psychological tips, survival techniques, and locations
of medical and health facilities. 7
Disaster Medicine 1.3.3 Response
Medical and health response to disasters includes the following:
1) Casualty site management
Casualty site management or disaster site management is the management of
the casualties at the site of disasters. The basic aim is to prevent deaths,
disabilities and diseases. It means immediate care and attention to the victims.
The activities include the provision of medical facilities, and transportation of
the affected to the health camps. The principle to be adhered is to rescue the
victims without aggravating their existing injuries. Triage forms an important
part of evaluating the state and conditions of the victims, which helps in sorting
and categorising them as per their condition and treatment required. Resuscitation
also begins simultaneously.
Communication forms an important part of the casualty site management. Journal
of Postgraduate Medicine states that a disaster generally involves normal
communication network. It is necessary to have communication between disaster
site and hospitals, so that the patients can be distributed to various hospitals
depending upon their capacity and load. According to Vasant Dave,
communication should remain operational under severe weather conditions,
should be uncomplicated, and should possess in-built flexibility to accommodate
additional emergency related services. Also, oral communication should be such
that there is little room for vagueness, ambiguity or misunderstanding.
The ambulatory service has an important role to perform in casualty site
management, especially in transportation of the disaster victims from the field
to the hospitals. According to the Medical Preparedness for Disasters, this
service is concerned with triage and treatment of casualties, on-site
communication, setting up of triage area and casualty collection point, liaison
with medical personnel for the selection of most appropriate hospitals, and also
liaison with fire and police.
Casualty site management is not all medical. Rather, it is administrative in nature
too. The administrative tasks include law enforcement, site surveillance and
supervision, water supply, identification of health facilities, and evacuation and
accessibility of roads.
2) Clinical casualty management
It deals with the management of the casualties, once they arrive in the hospital
emergency. Response begins with the following steps:

Communication

Transportation

Hospital alert

Expansion of the casualty area

Security

Hospital triage

Clinical care

Support services- medicines, blood bank, light arrangements, engineering,
sterilisation, medical records etc.

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Public relations and information system


Medico-legal aspects Understanding
Disaster Medicine

Discharge system

Documentation

Disposal of dead
3) Community participation in health management
Community participation is an important part of community health management.
Response becomes effective with community involvement. The State Disaster
Management Plan of Maharastra states that community participation can be
ensured by:

Identifying opinions, positioning leaders and voicing administration’s
confidence in their capabilities to undertake the tasks.

Consultations and dialogues to encourage the community and its leaders to
come forward.

Having regular feedback meetings and an open book approach to
demonstrate transparency.

Involving community in decision making at local levels.
Community participation in health management would help in:

Maintaining security and law and order.

Emergency evacuations.

Containing panic behaviour, and maintaining orderly movement towards
shelters.

Encouraging self help and contributing labour, such as, loading and unloading
patients, distribution of medicines, giving first aid etc.

Maintaining standards in sanitation and waste disposal.
4) Health response with Information and Communications Technology
(ICT)
Health response becomes better with the use of ICT. With the help of satellite
based communication systems, it has become possible to apply ICT in disaster
management. With the help of Geographic Information System, it has now
become easy to create databases, create knowledge bases, use management
information systems, use decision support systems, and access expert systems.
ICT helps in:

Prediction, warning, forecasting

Risk assessment and vulnerability analysis

Disaster preparedness, response, recovery

Epidemiological surveillance

Tele-monitoring

Communication

Records management
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Disaster Medicine
Medical transcription

Documentation

Tele-medicine

Studying environmental hazards

Land use planning

Simulation modelling and scenario analysis

Education and training

Teleconferencing

Spreading awareness

The Handbook of Disaster Medicine lays down that medical authorities in charge
of the emergency management must make decisions about counter measures to
be implemented to ensure effective and efficient emergency response. Decision
Support Systems (DSS) have been and are being developed to assist decision
makers in selecting and implementing response plans. A DSS is generally an
automated system in the form of computer software and its components include
registration of accident information, material information including health hazards
and recommendations for rescue and medical personnel, topographic information
with combined data on population density, information of transportation routes,
hazard level, damage calculations, evaluation of different counter measure
strategies, operational information and automatic emergency response actions.
This helps in accessing a large body of information, processing great quantities
of data, and the display of results in an orderly manner….This helps the medical
and health authorities to prepare an effective contingency response plan.

1.3.4 Recovery
It includes the following measures:

1) Psychological interventions

Disasters affect the people psychologically. It is necessary that the people

suffering from psychological problems or psychiatric disorders after the disaster
are given immediate and adequate psychological support. The disaster victims
tend to have various kinds of reactions that are sometimes emotional, cognitive,
physiological and interpersonal. People are exposed to stress, they may be
stunned, and they may be afraid and anxious. In the immediate post disaster
phase, people may experience insomnia, mood swings, nightmares, etc. There
are also signs of Post Traumatic Stress Disorder (PTSD), which the people
experience after few months of disaster. They re-experience the incident,
withdraw themselves from others, get highly irritated, have impulsive reactions,
and sleep disturbances.

Hence, certain remedial and curative measures have to be taken. These are:

Preparing people for an impending disaster.

Providing food and shelter, and shifting the people to safer places and making
them stay in groups.

Educating the people who are more likely to develop traumatic signs and
10 indications.

Dissemination and sharing of information and problems among peers. Understanding
Disaster Medicine

Training the community leaders in psychological counselling.

Harish Shetty describes psychological interventions as follows:

Identifying the mentally ill

Ventilation

Catharsis

Reassurance

Support

Family life education

Advice and empowerment

Spiritual explanation

Advice on livelihood issues

Talk

Myth negation

Mass grieving

Intervening in development issues, such as, providing information and

improving access to various schemes.

Providing general information about mental health to the community.

2) Critical incident stress de-briefing

As per the Report of the High Power Committee of the Government of India, it
is quite common for rescue workers involved in a disaster situation to develop
various psychosocial consequences. Workers may develop high levels of stress,
may be overwhelmed by the magnitude of the disaster and the enormity of
needs, and may experience feelings of powerlessness, helplessness and
hopelessness. The exposure to dead bodies can be very stressful. Therefore, it
is necessary that all workers are given an opportunity for emotional debriefing
during their work and also at the end of their work. Debriefing helps in mental
health recovery of the disaster workers. Debriefing involves going through, in
detail, the sequence of events as experienced by the worker, and helping the
worker to cope with stress adaptively. It should emphasise the positive aspects
of their work and help them to achieve a feeling of mastery over the unpleasant
features of disaster work. De-briefing should be conducted by those who are
specifically qualified and trained for the same.

Besides the above, recovery activities should take into account the cultural
aspects of the disaster affected community. The varying traditions, languages,
religions, customs, and food habits have to be taken care of by the disaster
workers.

Also, the recovery process pertains to restoration of infrastructure and other

facilities. This sometimes becomes complex as it involves coordination with
other bodies. It may take several years for the recovery process to be completed,
as new difficulties and issues keep on emerging from time to time. 11
Disaster Medicine
1.4 POST DISASTER REVIEW
The Australian Emergency Manual on Disaster Medicine lays down the following
as post disaster activities:

Review of the disaster plan with re-examination and revision of all
procedures.

Assessment of all stocks and stores and those used or found inadequate
should be replaced and refilled.

Documentation, which will help in medico-legal cases, clinical management
and research. The lessons learnt from the disasters should be properly
documented and used for all future planning and research.

Research to be undertaken and made a continuous activity. This will, in
turn, render qualitative education and training in the field.

1.5 CONCLUSION
Disasters have increased in frequency, intensity, and scale today. They cause
irreparable damages in terms of deaths, and injuries. They ‘ pose challenges
that are distinct from normal surgical practice, and require a paradigm change-
from the application of unlimited resources for the greatest good of each individual
patient to the allocation of limited resources for the greatest good of the greatest
number of casualties’.
Four important steps have to be taken to mitigate the adverse consequences of
disasters, and to provide a comprehensive and definitive medical care to the
disaster victims. These are:

Prevention of the disaster effects,

Preparedness for meeting emergencies,

Well laid down and practised system of response, and

Planned system of short-term and long-term recovery and rehabilitation.
These four steps will entail:

Multidisciplinary system of planning for disasters. The medical and health
personnel to participate in the entire planning.

Multi-stakeholders collaboration including community.

Integration and coordination of various services at all levels, such as
‘pre-hospital services, emergency management and public health agencies,
transportation and communication resources, defence, media, and health
care delivery facilities and personnel’.

Medical management of mass causalities following all disasters through
‘rescue, decontamination, triage, stabilisation, evacuation, and definitive
treatment’.

‘Resources and infrastructure of trauma centres to meet the logistical
demands and quick decision making required of massive disasters’.

Simulations for the community, and also for medicos/paramedics (hospital
drills).

Medical leadership and management of psychological trauma.

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Disaster education, training, research and review.

 Understanding
1.6 REFERENCES AND FURTHER READING Disaster Medicine

Australian Emergency Manual of Disaster Medicine, 1995, Emergency

Management Australia.
Report, Psychosocial Aspects of Disaster Management, 2001, HPC, Government
of India, Ministry of Agriculture, Krishi Bhavan, New Delhi.
Shetty, Harish, Psychological Interventions in Disaster: An Indian
Perspective, Paper presented in the International Conference on Disaster
Management: Cooperative Networking in South Asia, New Delhi, 28-30
November, 1999.
Prakash, Anjan, Role of Hospitals in Disaster Management, Paper presented
in the International Conference on Disaster Management: Cooperative
Networking in South Asia, New Delhi, 28-30 November, 1999.
Dave, Vasant, 1993, Seminar, DMI, Baroda (http://home.123india.com/vasantdave/
COMDISMA.htm
Noji, Eric K., 1997, The Public Health Consequences of Disasters, OUP, New
York.
Prehospital and Disaster Medicine, July-Sept. 2000, Vol.15. No. 3, ADEM,
Madison, Wisconsin, USA
Boer de Jan, Marcel Dubouloz, (ed.), July-Sept. 2000, Handbook of Disaster
Medicine, International Society of Disaster Medicine, Van Der Wees,
Netherlands.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt
= Abstract
http://en.wikipedia.org/wiki/Community_emergency_response_team
http://www.sos.se/sos/publ/refereng/9700-71e.htm (Medical Preparedness for
Disasters)
http://www.hope.be/07publi/leaflet/disaster/04-mp-ir.htm (Medical Preparedness
for Disasters)
http://en.wikipedia.org/wiki/Emergency_preparedness
www.un.org.in/images/undp-2Feb.
http://www.expresshealthcaremgmt.com/20030228/tech3.shtml
http://www.facs.org/fellows_info/statements/st-42.html
http://www.jpgmonline.com/article.asp?issn=0022-3859;year=1993;volume=
39;issue=1;spage
http://www.dhs.vic.gov.au/emergency/displan/medical_displan.html
http://www.educationtimes.com/infocus/tamingnature.htm

1.7 ACTIVITY
Narrate the ways you can help in health management of disasters in your State/
Region/Community.
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