Coping with Disaster

Most of Medical personnel during an emergency or disaster event often blinded by all the wounds and injuries and overlook the one essential part of being healthy; mental health well being. Disaster Mental Health is always being considered as the collateral damage of the disaster situation because of its nature of invisibility. Even though stress reactions immediately following a traumatic event are very common and most of the reactions will resolve within few days, it also can cause severe and long lasting reaction to trauma if the victim doesn’t cope well after the disaster crisis ends.

An event, or series of events, that causes moderate to severe stress reactions, is called a traumatic event. Traumatic event can potentially affecting those who suffer injuries or loss and can also reverberate in survivors, rescue workers, friends and relatives of victims who have been directly involved. In addition to those directly involved in the disaster, stress reaction can affect even with those not directly affected by the disaster such as those who have witnessed the event either firsthand or on television. Different people will react to traumatic event differently and highly depend on their ways of coping mechanism. Some victims even will feel that their world turns upside down after experiencing disastrous traumatic event.

As a health professional, our main objective of managing this problem is to provide general strategies for promoting mental health and resilience in disaster victims. We need to always keep in mind that it takes time for those victims to start feel better, so we need to be patient in handling these patient. We are also encouraged to referring those affected to the disaster event as survivors instead of victims. The psychological first aid is used in communicating with traumatic victims that basically encompasses of active listening and empathy. We can also try to advise them to stay busy and follow their normal routines as much as possible whilst limit their time around the sights and sounds of what happened and don’t dwell on TV, radio, or newspaper reports on the tragedy. it will only haunt their memory. Lastly, as cherry on top, eat healthy meat by carefully not to skip meal or to overeat and exercise to stay active.

Some people are at greater risk than others for developing sustained and long-term reactions to a traumatic event including disorders such as post traumatic stress disorder (PTSD), depression, and generalized anxiety. Factors that contribute to the risk of long-term impairment such as PTSD are listed.

• Proximity to the event. Closer exposure to actual event leads to greater risk (dose-response phenomenon).
• Multiple stressors. More stress or an accumulation of stressors may create more difficulty.
• History of trauma.Meaning of the event in relation to past stressors. A traumatic event may activate unresolved fears or frightening memories.
• Persons with chronic medical illness or psychological disorders 

 But in the end,

CDC | Disaster Mental Health

Disaster Victims Identification

In case of mass casualty incident, it means a lot of dead body with unknown identity. Since situation is worse when the incident occurs causing the dead body to unable to be recognized and some of the body may be mutilated and it is impossible to find any personal identification on that body. Interpol has set a guide on how to identify disaster victim. Disaster Victim Identification (DVI) team consist of several victim identification unit with  specific duties and responsibilities.

• Recovery and Evidence Collection Team - The Recovery and Evidence Collection Team is responsible for the recovery of bodies at the disaster site and the collection and preservation of evidence and property at the site as well as the personal effects of victims within the extended area around the disaster site.
• Ante Mortem Team - The AM Team collects ante mortem data required for the identification of victims, prepares corresponding missing‐persons files and notifies the relevant authorities regarding completed identifications. 
• Post Mortem Team - The PM Team collects all relevant dental medical and forensic data obtained from the bodies of deceased victims for the purpose of identifying said victims. The team consists of experts in the fields of fingerprint analysis, forensic pathology, forensic odontology and DNA analysis. 
• Reconciliation Team - The Reconciliation Team is responsible for matching AM and PM data records, which ultimately leads to victim identification. In cases in which matches are identified, the Reconciliation Team submits the corresponding documents to the Identification Conference for review and final decision. 
• Care and Counselling Team - The Care and Counselling Team provides medical and psychological care and counselling for personnel in the Recovery, Evidence collection and Victim Identification unit. The team is also the point of contact for relatives of disaster victims within the context of family assistance. The team receives professional support for this difficult work from physicians and trained psychologists. 
• Identification Board - The Identification Board is a group of experts which meets at regular intervals to discuss and verify proposals submitted by the Analysis/Reconciliation Team. The Board makes final decisions regarding the identification of given victims and certifies these decisions on the DVI form.

According to the DVI procedure of Interpol, there are five steps to manage the dead victims of disaster. All the DVI team will be involve in the steps.

1. At the scene of incident
2. Collecting post mortem data
3. Collecting ante mortem data
4. Comparison of ante mortem and post mortem data (Reconsiliation)
5. Identification

At the scene of incident, the recover and evidence collection team will collect the body and make a skectch and photograph the location of body is found. They also need to recover all belonging/goods that surround the dead body and all evidences need to be sent together to the post mortem team for further examination. As the body arrive in the hospital, ante mortem and post mortem data is usually collected parallelly as both data will be needed in the next  reconsilation process. Data collected in this step can be primary or secondary from the body and will be used to identify that victim. As the end result of this whole process, a victim can be identified or not identified with several degree of certainty; possible, indeterminate or inconclusive and positive identification. This degree of certainty is in regard to the data that is being used to identify the patient as DNA comparison, dental record and fingerprint as the highest identification certainty.

INTERPOL Disaster Victims Identification Guide

Disaster and Disaster Management

The picture above is a conceptual framework of a disaster and disaster management with left part of it is the process of a disaster to occur and right part is the disaster management. As we know, disaster can be categorized to man made and natural disaster, and both type of the disaster events can be explain following this disaster framework. HAZARD is something that contents energy, so it could be an airplane or a volcano. At one time, something that content that much energy, must has a probability that some bad could happen, this is what is known as RISK. Thus realization of the hazard, i.e. volcano eruption is the event. Not a disaster yet, because certain things a required in order an event to be classify as a disaster. When an event comes into contact with those who has the vulnerabilities, this is the IMPACT of that event, and a negative result from an impact of an event resulting in damages. Be the DAMAGE is in the sense of social function, loss of life or property it still just an event circumstances. When the local government of where the event has occurred demand the needs of external aid for recovery, then it will finally be qualified as a DISASTER.

As you can see, the framework appears as a process, but in fact, it is actually an endless loop of event. Therefore the disaster management must be work to cut off or to end even this loop. The first steps of a disaster management is to prevent it from happening. PREVENTION is done to reduce the possibility of a hazard from going wrong and realization of its hazard. This mainly only possible in preventing man made disaster as we can only reduce and prevent the hazard of airplane and not a volcano. For example, we can design a plane with a better aviation system thus reducing the hazard. MITIGATION on the other hand, i usually used to minimize the after effect of an event. When early warning of an event already being confirm, here disaster management is the preparation to come face to face with the event. PREPAREDNESS embodies all plans that being done before the event occurs including evacuation plan, early detecting warning system and so on. During the disaster period, RESILIENCE take place in disaster management. This include the initiation of medical response, search and rescue team and initiation of rapid response team. In the evacuation camp, two terms is important reflecting the success of disaster logistic system; absorbing capacity and buffering capacity. Absorbing capacity is the capacity of the camp or hospital to receive the number of victims and buffering capacity the amount of inventories that was stored to be used disaster emergency situation. Disaster management for post disaster is the RECOVERY and DEVELOPMENT of the all the damages caused by its impact.

S. Triage. A. R. T.

"The bad artists imitate, the great artists steal." - Pablo Picasso H. Semat

Triage is a procedure of sorting of patients to priority-based category for transport and treatment according to degree of injury severity and medical emergency, in regard of first aid ABC system procedure (in field or hospital). Triaging includes selecting system in scene of accident by the responder and evacuating/transporting patients to the hospital or other health care facilities. For patient identification purposes, easiest way is by using colored-coded Triage Tag and the priority of patient management in triage are as follows:

• Highest Priority/Immediate/Class 1 (RED) : Emergency and life threatening patient (immediate care and life threatening)
• High Priority/Delayed/Class 2 (YELLOW) : Moderate and emergency patient (urgent care and can be delayed up to 1 hour)
• Immediate Priority/Minor/Class 3 (GREEN) : Emergency not life threatening, life threatening not emergency and not emergency and not life threatening (delayed care and can be delayed up to 3 hours)
• Last Priority/Class 4 (BLACK) : Probable death and patient with signs of death (victim is dead and no care required)

START on the other hand stands for Simple Triage and Rapid Treatment/Transport which is a modified triage commonly used in managing Multiple/Mass Casualty Incident (MCI). This system is done by the help personnel in 60 seconds or less for each patient and encompasses respiration, circulation and mental status examination. START system divides victims to 4 priorities exactly as in conventional triage with some modification as less time required to perform triage on mass victims.

• Immediate/Highest (RED)
• ventilation is present after airway is secured, or breathing is more the 30x/min
• capillary refill/filling more than 2 seconds
• unable to follow simple command
• Delayed/High (YELLOW)
• patient can't be categorized in immediate or minor
• Minor (GREEN)
• separated from the victims in the beginning of triage operation and usually known as "walking wounded"

Triage Tag is usually filled and done during the transport of victim to the hospital. Pay attention to details of;

1. time arriving to the scene of incident
2. date of incident
3. name (if conscious and coherent)
4. address
5. other important infomations
6. help personnel indentity
7. identification of traumatic patient (with photo)
8. vital sign and time of examination
9. record usage of IV drugs and other drug (advance life support)
10. place the tag on the cloth or on other part of easy to be noticed

 and examination of 3, 4, 5 can be postponed and completed in awaiting the transport team to be arrived.

Ref: Buku Panduan Pelatihan Basic Life Support TBMM FKUGM

Code of Professional Conduct

Doctors are bound to work professionally and becoming the leading in health care profession. Being a doctor is a highly paid profession which also demanded a high level of professionalism. This statement is seems recursive for most doctors bur this kind of lame platitude is needed to really remind us that we carry a heavy burden on our shoulder. Need I to remind:

The International Code of Medical Ethics (Excerpts)

"At a time of being admitted as a member of the Medical Profession:
I solemnly pledge myself to consecrate my life to the service of humanity:
I will practice my profession with conscience and dignity;
The health of my patient will be my first consideration;
I will maintain by all means in my power, the honour and noble traditions of the medical profession;
I will not permit considerations of religions, nationality, race, party politics or social standing to intervene between my duty and patients.
I will maintain the utmost respect for human life from its beginning even under threat, and I will not use my medical knowledge contrary to the laws of humanity."

The Declaration of Geneva (Excerpts)

I solemnly pledge myself to consecrate my life to the service of humanity.
I will practice my profession with conscience and dignity.
The health of my patient will be my first consideration.
I will respect the secrets which are confided in me.

General Medical Council (GMC) of UK had used several terms to describe the medical professional in action and they come out with Good Medical Practice as a principles and values as guidance which is addressed to General Practioners working in UK. Since Malaysia adapted their health care system mainly based on their former colonist British system, Malaysian Medical Council (MMC) has also set 10 principles for Malaysian doctor in defining a good medical practice. According to their published article about Duties of a Doctor, Good Medical Practice are:

The Ten Golden Rules of Good Medical Practice

1. Practise with Kindness, Ethics and Honesty.
2. Upgrade Professional Knowledge and Clinical Skills.
3. Maintain good Patient Records.
4. Maintain good Communication with Patients and Relatives.
5. Maintain Doctor-Patient Confidentiality.
6. Allow Second Opinion and Referral to Colleagues.
7. Maintain good Working Relationship With Colleagues.
8. Be conscious of Cost of Healthcare.
9. Avoid Publicity, Self-promotion and Abuse of Position.
10. Be a Partner in promoting Global Health.

Code of professional conduct are embodied in various Codes of Ethics which vary in detail from country to country but all place first and foremost the health and welfare of the individual and the family under the care of a practitioner. The MMC endorses the International Code of Medical Ethics and Declaration of Geneva which embodies these ideals, thus underpinning the Code of Ethics are statutes which make it an offence punishable under the law of the country to transgress certain outer limits of the expected norms of professional conduct. These minimum standards of conduct are assessed by their peers in the profession, assembled as the MMC established under the Medical Act 1971. Breaches of these minimum standards are referred to as 'infamous conduct in a professional respect' or 'serious professional misconduct'. This Code of Professional Conduct can be downloaded from MMC websites and the pdf file contain the definition of 'infamous conduct in professional respect', form of infamous conduct and disciplinary procedure to the convicted doctor.