Terrorism, Mass Casualty and Disaster Nursing

Terrorism: “ the unlawful use of force or threats of violence against people in order to intimidate or coerce

Mass Casualty Incident (MCI): “a situation in which the number of casualties exceeds the number of resources”

Disaster Nursing: “the adaptation of professional nursing knowledge, skills and attitude in recognizing and meeting the nursing, health and emotional needs of disaster victims.”

DISASTER NURSING“Doing the best for the most, with the least, by the fewest”

Definition: “The adaptation of professional nursing knowledge, skills and attitude in recognizing and meeting the nursing, health and emotional needs of disaster victims.”

Goal: “To achieve the best possible level of health for the people and the community involved in the disaster.”

PRINCIPLES OF DISASTER NURSING

Rapid assessment of the situation and of nursing care needs.

Triage and initiation of life-saving measures first.

The selected use of essential nursing interventions

Adaptation of necessary nursing skills and resourcefulness in dealing with a lack of supplies, equipment, and personnel.

Evaluation of the environment and the lessening or removal of any health hazards.

Prevention of further injury or illness.Leadership in coordinating patient triage,

care, and transportThe teaching, supervision, and utilization

of auxiliary medical personnel and volunteers.

Provision of understanding, compassion, and emotional support to all victims and their families.

Classification Levels for Disasters

Classified by the anticipated necessary response

Level I: Local emergency response; personnel and organizations

Level II: Regional assistance is needed from surrounding communities

Level III: Statewide or federal assistance

Federal Agencies Federal agencies that may provide resources in

response to mass casualty or disaster include: Department of Health and Human Services (DHHS)

DMORTs NVRTs IMSuRTs

Disaster Medical Assistance Teams (DMATs) organize voluntary medical personnel (Health care providers, nurses, EMT’s, Technical Staff, and other health care professionals)

Department of Justice (DOJ) Department of Homeland Security

Emergency Operations Plan (EOP)Health care facilities are required by the

Joint Commission (TJC) to create a plan for emergency preparedness and to practice this plan twice a year

Essential components of the plan:◦ An activation response◦ An internal/external communication plan◦ A plan for coordinated patient care◦ Security plans◦ Identification of external resources◦ A plan for people management and traffic flow

Emergency Operations Plan (EOP)Essential components of the plan cont.

A data management strategyDeactivation responsePost-incident responseA plan for practice drillsAnticipated resourcesMass casualty incident planningEducation for all of the above

The Nurse’s Role in Disaster Response Plans

Nursing care in a disaster focuses on essential care from a perspective of what is best for all patients.

Depends on the specific needs of the facility for patient care (Atypical roles)

Serve as a triage officerTake roles normally held by physicians based

on their area of expertise. i.e. CCN may intubate patients

DISASTER MANAGEMENT CYCLE

The Disaster Event: Real-time event of a hazard occurring The response phase is the actual implementation of the disaster plan

Recovery the organization and staff needs to recover

Evaluation & Development: determine what went well

Mitigation: ways to lessen the impact of a disaster

Preparedness: Evaluate the facility’s vulnerabilities for disasters

TriageDetermines priority health care needs and the

proper site of treatment.In non-disaster situations, the highest

priority and allocation of resources are for the most critically ill.

In disaster situations with large numbers of casualties, decisions are based on survival and the consumption of resources

Triage categories separate patients according to severity of injury.

Triage Categories:

Triage Description Color

Emergent Immediate threats to life. Require immediate attention.

RED

Urgent Major injuries. Requires treatment 30 mins-2 hours

YELLOW

Nonurgent Minor injuries. Can be treated in a delayed fashion >2 hours

GREEN

Expectant/Deceased

Expected to die or is deceased BLACK

TYPES OF TRIAGETwo types of triage:

Simple triage S.T.A.R.T. (Simple Triage and Rapid Treatment) performed by

first responders and emergency personnel in emergencies.     0 – The deceased who are beyond help 1 – The injured who can be helped by immediate

transportation 2 – The injured whose transport can be delayed 3 – Those with minor injuries, who need help less urgently

Advanced triage Diverts scarce resources away from patients with little

chance of survival in order to increase the chances of survival of others who are more likely to survive.

“Do the greatest good for the greatest number” Ethical decisions are made

Critical Incident Stress Management (CISM)

Critical Incident Stress Management (CISM) is implemented to prevent /treat emotional trauma affecting emergency responders

Incident stress can affect anyone who is involved in a disaster or mass casualty.

Agencies, resources and education are made available Defusing is a process by which the person

receives education about recognition of stress reactions and management strategies for handling stress.

Personal Protective Equipment (PPE)

The purpose of PPE: shield health care workers from the chemical, physical, biologic, and radiologic hazards that may exist when caring for contaminated patients.

Chemical or biologic agents and radiation are silent killers (color-less and odorless)

U.S. Environmental Protection Agency (EPA)hasFour categories Levels A – D

Personal Protective Equipment (PPE)

PPE donned before patient contactUse specific PPE based on agent involvedTraining is required

Personal Protective EquipmentLevel A – highest level of

respiratory, skin and eye, fully encapsulated chemical resistant suit, full face piece and supplied air (self-contained breathing apparatus or SCBA)

Level B - protection requires the highest level of respiratory protection but a lesser level of skin and eye protection than with level A situations.

Level C – Full face piece with air purifying canister-equipped respirator, chemical-resistant clothing (including gloves & boots)

Level D – Regular work clothing, safety shoes, goggles/splash shield

DecontaminationReduction or removal of

contamination agents.Radioactive agents –

the runoff also needs to be contained

Victims need to be decontaminated before they can be admitted to the emergency facility or hospital

Terrorism

Disrupt Daily Life & Cause Terror and Panic FBI definition– “the unlawful use of force or

violence against person’s or property to intimidate or coerce a government, the civilian population, or any segment thereof, in furtherance of political or social objectives”

Blast Injuries

Physical Injuries After Blast EventsBlast LungTympanic Membrane Rupture Abdominal and Head Injuries

Biologic WeaponsBiologic weapons are weapons that spread diseaseBacteria - Viruses - ToxinsDelivered in either a liquid or dry state, applied to foods or

water, or vaporized for inhalation or direct contact. Anthrax the most likely biologic agent available; a highly

debilitating agent for centuries. Bacteria releases toxins causing hemorrhage, edema,

and necrosis. Penicillin sensitive; initiate treatment within 24 hours

Smallpox (variola) is a DNA virus. Incubates 12 days. Highly contagious and is spread by direct contact, by contact with clothing or linens, or by droplets. Patient isolation and antibiotic therapy.

Chemical Weapons Chemical substances that quickly cause

injury and/or deathAgents

Nerve agents Blood agentsVesicantsPulmonary agents

Agents vary in volatility, persistence, toxicity, and period of latency

Limitation of exposure is essential with evacuation and decontamination

Radiation ExposureRadiation exposure may occur due to nuclear weapon

or exposure to radioactive samples Signs and symptoms determine predicted survival;

most common nausea and vomiting persists for 24-48 hours

Improbable survivors are acutely ill with nausea, vomiting, diarrhea, and shock. Neurologic symptoms suggest lethal dose. Survival time is variable

Radiation DecontaminationTriage outside the hospitalCover floor and use strict isolation precautions

to prevent the tracking of contaminantsAir ducts and vents are sealedWaste is double bagged and labeled radiation waste

Psychological Effects After a Disaster

Provide active listening and emotional support

Provide information as appropriate

Refer to therapist or other resources

Discourage repeated exposure to media regarding the event

Encourage return to normal activities and social roles

The point is to save as many people as possible!