Medical support for disaster survivors (msds) ali
- 1. Medical Support for Disaster Survivors (MSDS) • Ali Menhem
- 2. 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.
- 3. Medical Support Definition Medical support Disaster medicine Disaster management
- 4. 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)
- 5. Disaster Types • Natural • Man-made ‒ Accidental ‒ Malicious 5 Tornado Natural Disaster Chernobyl Technological Disaster
- 7. Man-Made Disasters • Accidental ‒ Factory Explosions ‒ Air or Sea disasters ‒ Fires ‒ Hazardous Material spills (HAZMAT) • Malicious ‒ Terrorist Activities ‒ Civil / Regional conflicts – WAR ‒ Embargos & Sanctions 7
- 8. What do disasters affect? 8 • People • Places • Things
- 9. Natural Disasters in Lebanon .
- 10. Man Made Disasters in Lebanon • Structural Collapse Terrorist Activities • Fires
- 11. 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 11
- 12. Emergency Management Mission Areas 12 PREVENTION PROTECTION RESPONSE RECOVERY MITIGATION
- 14. Steps in the Disaster Planning Process 14
- 16. Responsibility for Plan Development Emergency Manager A 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 31
- 17. • 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 the Emergency Manager 32
- 18. 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 the foundation for subsequent National Preparedness System activities.
- 19. 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.
- 20. 35 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
- 21. Hazard Analysis and Risk Assessment 36 Orientation to Group Activity
- 22. 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, 2006 37
- 23. 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 38
- 24. 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 39
- 25. 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 40
- 26. Water Supply Access is as important as quantity! 41
- 27. 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 42
- 28. 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
- 29. 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 44
- 30. 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. 45
- 31. 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 46
- 33. 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 48
- 34. 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 49
- 35. 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 50
- 36. 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 51
- 37. 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 52
- 38. 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 53
- 39. 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
- 40. 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 55
- 41. Vector Control & Pest Management 56
- 42. Contributing Factors • Inadequate or absent housing • Placement of camps near water • Overcrowding • Poor health, malnutrition, co-infections 57
- 43. 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 58
- 44. 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 59
- 45. 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 60
- 46. 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 61
- 47. 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 62
- 48. 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 63
- 49. 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 64
- 50. 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 65
- 51. 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) 66
- 52. 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
- 53. Food Security 68
- 54. Assessing Food & Nutrition • Type, degree, and extent of food insecurity & malnutrition • Determine those most affected • Best response 69
- 56. Assessing Food & Nutrition • Type, degree, and extent of food insecurity & malnutrition • Determine those most affected • Best response 71
- 57. Micronutrient Deficiency Deficiency Potential Symptoms Vitamin A deficiency Night blindness Bitots spots Corneal Xerosis/ulceration/keratomalacia Corneal scars Serum retinol Iodine deficiency Goiter Median urinary iodine concentration (mg/l) Iron deficiency Anemia Thiamine deficiency (Beriberi) Anorexia/malaise Cardiac involvement with edema Peripheral neuropathy Niacin deficiency (Pellagra) Dermatitis Digestive tract and nervous system may be involved Anxiety/depression Vitamin C deficiency (Scurvy) Hemorrhages Bone lesions 72
- 58. 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 73
- 59. 74 Shelter, Settlement Management and Planning, Non-Food Items.
- 60. 75
- 61. Camps Versus Integration in Community • Advantages and disadvantages to both • May be self-selection but not always • May be mixture of camps and host communities 76
- 62. Camp Setting: What are advantages 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 77
- 63. 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
- 64. Coordination Between Camp Leaders And Organizations is Essential 79
- 65. 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 80
- 66. 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
- 67. 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
- 68. Non-Food Items 83 Requires adequate storage facilities and distribution system
- 69. 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
- 70. 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
- 71. Casualty Management in the Field: Triage & Hospital Levels of Care Decisions may be based upon: • Golden hour concept & Triage • Evacuation procedures • Hospital Treatment capabilities
- 72. 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
- 73. 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 88
- 74. Triage (sorting casualties) 89 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.
- 75. 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
- 76. 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. 91 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
- 77. 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: 92 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
- 80. 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. 95 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
- 81. 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.
- 82. Other considerations • Neurosurgical, Radiology support • Blood products, and supplies. • Weather, Roads, accessibility • Language, cultural differences • Number of patients already transported there. • Availability of transport 97
- 83. 98 Battlefield Care Role 1 Forward Surgical Care Role 2 Deployed Hospitals Role 3 Regional Evacuation Hub Role 4 CASEVAC < 1 hour TACTICAL MEDEVAC 1-24 hours STRATEGIC AE 24-72 hours
- 84. 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 99
- 85. Mass Casualty and Triage Principles Objectives • Review mass casualty principles • Review triage principles • Having a system in place • Goals 100
- 86. Triage and Evacuation 101 INCIDENT SITE 1 - Immediate CCS 2 - Urgent 3 - Delayed 4 - Expectant DEAD MEDEVAC Loading Point Receiving Hospital Receiving Hospital Receiving Hospital T4 T1 T2 Body holding area Temporary morgue
- 87. 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
- 88. 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
- 89. NGO Duties • Health promotion • Manage health crises • Community social problems • Environment • Economic • Infrastructure development • Women’s issues • Child welfare 104
- 90. 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. 105
- 91. • List of hospitals in Lebanon