Mental Health Consequences of Bioterrorism - Year 2: An Advanced Course for Hospital Emergency...

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Mental Health Consequences of Bioterrorism - Year 2: An Advanced Course for Hospital Emergency Department Clinical Staff
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Page 1: Mental Health Consequences of Bioterrorism - Year 2: An Advanced Course for Hospital Emergency Department Clinical Staff.

Mental Health Consequences of Bioterrorism - Year 2:

An Advanced Course for Hospital Emergency Department

Clinical Staff

Page 2: Mental Health Consequences of Bioterrorism - Year 2: An Advanced Course for Hospital Emergency Department Clinical Staff.

Supported by Grant Number U3RHS04301-01-00 from the Health Resources and Services

Administration (HRSA). Its contents are solely the responsibility of the authors and do not

necessarily represent the official views of HRSA.

Disclaimer

Page 3: Mental Health Consequences of Bioterrorism - Year 2: An Advanced Course for Hospital Emergency Department Clinical Staff.

Acknowledgments

Written by Rebecca Smith, MD

Curriculum Development & Review Committee:Grant Brenner, MDKristina Jones, MD

G Luke Larkin, MD, MS, MSPH, FACEPCraig L Katz, MD

Roger Nathaniel, MDCarol North, MD, MPEIlisse Perlmutter, MD

Page 4: Mental Health Consequences of Bioterrorism - Year 2: An Advanced Course for Hospital Emergency Department Clinical Staff.

Why another course in psychosocial aspects of

bioterrorism?

Page 5: Mental Health Consequences of Bioterrorism - Year 2: An Advanced Course for Hospital Emergency Department Clinical Staff.

OverviewDidactic - 20min Using the SARS epidemic, we’ll illustrate:

• Key psychosocial dimensions of a bioterrorist attack relevant to ED staff

• ED staff are at increased risk for being both victim and vector

• Communication between individuals, institutions and groups about risk appraisal

Cases – 50min• Applications to ED staff• Psychosocial preparedness & mental health issues • Development of risk communication – based

strategies for individuals and groups• Differentiation of acute presentations of severe

distress from diagnosis, Integration of psych first aid into routine care.

Page 6: Mental Health Consequences of Bioterrorism - Year 2: An Advanced Course for Hospital Emergency Department Clinical Staff.

Emergency vs. Disaster

• As ED staff, you all handle the extraordinary, QD!• You always have capacity to handle the

extraordinary, right? But...• In disasters, needs exceed capacity, for ALL

systems, even the ED – Normal procedures insufficient.

• What will it be like for YOU to be in a situation where needs exceed capacity?

Page 7: Mental Health Consequences of Bioterrorism - Year 2: An Advanced Course for Hospital Emergency Department Clinical Staff.

Core Competencies

1. Identify psychosocial vulnerabilities of ED Health Care Workers as first responders in BT attack & develop a plan for preparedness

2. Understand principles of risk communication & apply to communication with individuals & crowds

3. Differentiate distress v. diagnosis– Common post-disaster mental health myths– PTSD symptoms ≠ PTSD!

4. Integrate Psychological First Aid into care

Page 8: Mental Health Consequences of Bioterrorism - Year 2: An Advanced Course for Hospital Emergency Department Clinical Staff.

Psychosocial Vulnerabilities of ED Health Care Workers

• ED Health Care Workers are First Responders for the nation, 24/7

• ED already a combat zone of austerity & overcrowding

• Increased Risk for Infection in EDVictim/Vector

• Big changes in work and home role

Page 9: Mental Health Consequences of Bioterrorism - Year 2: An Advanced Course for Hospital Emergency Department Clinical Staff.

SARS timeline

ABCDEFGHIJKLM

Onset of symptoms Time stayed at Hotel M

February March4 531 624 25 26 227 2820 21 22 2315 16 17 18 19

Hotel MetropoleHong Kong

From Brendan Flannery, PhD, the CDC SARS Investigative Team

Page 10: Mental Health Consequences of Bioterrorism - Year 2: An Advanced Course for Hospital Emergency Department Clinical Staff.

Hotel MHong Kong

Guangdong Province,

China A

A

H,J

A

H,J

Hong Kong SAR

95 HCW

>100 close contacts

United States

1 HCW

I, L,M

I,L,M

KIreland

0 HCWK

Singapore

34 HCW

37 close contacts

C,D,E

C,D,E

B

B

Vietnam

37 HCW

21 close contacts

F,G

Canada

18 HCWF,G

11 close contacts

SARS transmission:Health Care Workers & Families

Page 11: Mental Health Consequences of Bioterrorism - Year 2: An Advanced Course for Hospital Emergency Department Clinical Staff.

Example: SARS8437 Probable Cases

China: 5327(Beijing: 2521)

(Guangdong: 1511)

H.K.: 1755

Viet Nam: 63

Singapore: 206

Canada: 250(Toronto: 242)

Taiwan: 671

As of July 11, 2003. Source: WHO

Page 12: Mental Health Consequences of Bioterrorism - Year 2: An Advanced Course for Hospital Emergency Department Clinical Staff.

Isolation & Quarantine

• Both are methods of “community containment.”• Isolation: the separation of persons who have a

specific infectious illness from those who are healthy, and the restriction of their movement to stop the spread of disease.

• Quarantine: the separation and restriction of movement of persons who, while not yet ill, have been exposed to an infectious agent and therefore may become infectious.

• Both can be either voluntarily or compelled by public health authorities.

Page 13: Mental Health Consequences of Bioterrorism - Year 2: An Advanced Course for Hospital Emergency Department Clinical Staff.

Toronto Outbreak, Spring 2003Paramedics on Quarantine

0

20

40

60

80

100

120

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39

Day of Outbreak

# o

f p

ara

me

dic

s

Total Staffperson-Days on Quarantine = 2035

Page 14: Mental Health Consequences of Bioterrorism - Year 2: An Advanced Course for Hospital Emergency Department Clinical Staff.

2003 SARS Outbreak Acute Psychological Responses

• Patient reactions:– Isolation, loneliness, stigma– Anxiety associated with fever spikes– Fear and guilt about well-being of family/friends

– Insomnia

• Staff reactions:– Conflict between work & family responsibilities– Complexity of caring for other HCWs

– Diminished control, freedom, self-esteem

(Maunder et al, 2003)

Page 15: Mental Health Consequences of Bioterrorism - Year 2: An Advanced Course for Hospital Emergency Department Clinical Staff.

Personal Preparedness Planning• You have a disaster plan at work. The hospital has one.

– Do you know it?• But do you have a disaster plan for yourself and your family?• What sorts of BT training & support are available for you in

your hospital or on the web?• Bioterrorism Literacy:

– What is ICS? – State and Hospital plans and policies re: Quarantine &

Isolation?• Psychosocial Literacy:

– What are your sources of resilience?– How do you actively cope?

Page 16: Mental Health Consequences of Bioterrorism - Year 2: An Advanced Course for Hospital Emergency Department Clinical Staff.

Principles of Risk Communication: Treatment and Prophylaxis

for Anxiety and Panic1. Listen to, acknowledge, and respect the fears, anxieties and uncertainties:

- they want to know that you care before they care what you know.

2. Appear calm and in control, even in the face of public fear, anxiety and uncertainty; provide others with ways to participate, be constructive, channel their energy, and regain control.

3. Offer authentic statements of caring, empathy, compassion and listening; back up those statements with actions.

4. Be honest, ethical, frank, and open, recognizing that there are limits on what needs to be disclosed.

5. Avoid using humor; if humor is needed, plan and test carefully.

Page 17: Mental Health Consequences of Bioterrorism - Year 2: An Advanced Course for Hospital Emergency Department Clinical Staff.

Principles of Risk Communication

6. Be hopeful so as to avoid fixation on the negative.- avoid the five N’s: no, not, never, nothing, none

7. When providing info or sharing bad news, be proactive but remember – Need 3 positives to balance 1 negative.

8. Avoid mixed or inconsistent verbal and non-verbal messages

9. Hone verbal & non-verbal media skills. - Avoid major media traps, guarantees, speculating on worst case

scenarios. Covello, 2004

Page 18: Mental Health Consequences of Bioterrorism - Year 2: An Advanced Course for Hospital Emergency Department Clinical Staff.

Assessing Patients Psychological Assessment Principles

• What is known about the event, including its known scope, impact, and public health implications?

• Who is the person in front of me, including their personal, social, and psychological history as well as their connection to the disaster?

• When in the time course of the event is their ED visit occurring?

Katz, 2004

Page 19: Mental Health Consequences of Bioterrorism - Year 2: An Advanced Course for Hospital Emergency Department Clinical Staff.

Acute Psychological Responses (intense but changeable)

• “Stunned”• “Shocked”• Anger at authority• Feeling abandoned• Uncommon vulnerability• Exaggerated rumors• Intense love / altruism• Heroism / Industry• Desperation

• Bewilderment• Fear• Impasse• Numbness• Apathy• Helplessness• Urgency• Discomfort• Confusion

(Wolfenstein, 1957)(Katz et al, 2002, 2004)

Page 20: Mental Health Consequences of Bioterrorism - Year 2: An Advanced Course for Hospital Emergency Department Clinical Staff.

Bioterrorism and Mental Illness

• Acute Stress Disorder (can only diagnose within 30 days of trauma)

• Post Traumatic Stress Disorder (can only diagnose AFTER 30 days post-trauma)

• Major Depressive Episode/Disorder

• Panic Attack/Panic Disorder

• Generalized Anxiety Disorder

Page 21: Mental Health Consequences of Bioterrorism - Year 2: An Advanced Course for Hospital Emergency Department Clinical Staff.

Assessing PatientsPsychological First Aid

• provide for basic needs (water, blankets, privacy)

• protect from further exposure – reduce environmental stimulation or agitation

• support the most distressed• keep families together & provide social support

– awareness of impact on entire family• provide information, foster communication and

education– orient to available services– use effective risk communication techniques

Page 22: Mental Health Consequences of Bioterrorism - Year 2: An Advanced Course for Hospital Emergency Department Clinical Staff.

Web Resources

• www.cdc.gov “emergency preparedness” • www.bt.cdc.gov “cdc bioterrorism info”• www.nyc.gov/health/nycmed 1-888-NYCMED9• Health Alert Network, gives you emails on alerts”

from the NYS dept of health and mental hygiene Email: [email protected]

• CDC health alerts, learning modules • www.phppo.cdc.gov/han/