Transcript Slide 1

DEEP
Center
Disaster Behavioral Health
Awareness Training for
Health Care Professionals
Copyright © 2004: All Rights Reserved
Disaster Behavioral Health Awareness
Training for Health Care Professionals
James M. Shultz MS, PhD
Zelde Espinel MD, MA, MPH
Raquel E. Cohen MD, MPH
Jorge R. Insignares MD
Lisa Rosenfeld MPH
DEEP Center
University of Miami
School of Medicine
Brian W. Flynn EdD
Rear Admiral, USPHS (Ret)
Assistant Surgeon
General (Ret)
Jon A. Shaw MD, MS
Department of Psychiatry
University of Miami
School of Medicine
Robert J. Ursano MD
Director, Center for the Study of
Traumatic Stress
Uniformed Services University
of the Health Sciences
Joseph A. Barbera MD
Director
Institute for Crisis, Disaster, and
Risk Management
The George Washington University
Mauricio Lynn MD
Abdul Memon MD
S. Shai Gold
Jackson Memorial Medical Center
University of Miami
School of Medicine
DISASTER BEHAVIORAL HEALTH AWARENESS TRAINING FOR HEALTH CARE PROFESSIONALS
DISASTER BEHAVIORAL
HEALTH CONCEPTS
Disaster Behavioral Health
Key Concepts
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Terrorism and disaster
Levels of exposure
Psychological vs. medical “footprint”
Who are the psychological casualties?
Stressors at the crisis scene
Reactions at the crisis scene
Community responses to disaster
Public fear and panic behavior
Public fear and hospital surge
Disaster Behavioral Health Training
Terrorism and
Disaster
Terrorism: A Subset of Disaster
Non-intentional/
Technological
Intentional
Mass Violence
Terrorism
Human-Generated
Disasters
Natural Disasters
Percentage of citizens with
severe psychological impairment
Mass
Violence
>
Technological
Disasters
>
Natural
Disasters
Source: Norris et al., 2002
Psychological impairment by
type of disaster
Psychological/behavioral impacts
from terrorism are:
 Larger in magnitude
 More serious
 More complex
 More long-term
 More costly
compared with natural disasters,
Source: Flynn, 2002
Terrorism: Human Causality
• An act of human intention
• An act of human malevolence
Acts of terrorism
are human-generated
intentional disasters
Disaster Behavioral
Health Awareness
Training is an
all-hazards course.
Everyone
is exposed
but levels
of exposure
differ.
Levels of Exposure
Citizens/survivors are
distinguished by:
Proximity to event
Intensity of exposure
Degree of personal harm
Role in response and recovery
Direct Impact Victims
Displaced/
Property loss
Injured
Killed
IMPACT
Direct Impact Victims
Directly exposed or injured
Direct Impact Victims
Displaced/Property damage
Citizens Sustaining Potential Psychological Impact
Family
Members
Witnesses
Friends
Direct
Impact Co-Workers
Victims
Disaster/
Emergency
Workers
Disaster-Affected Community
Distant Communities
Citizens Sustaining Potential Psychological Impact
Family Members
Citizens Sustaining Potential Psychological Impact
Friends
Citizens Sustaining Potential Psychological Impact
Co-Workers
Citizens Sustaining Potential Psychological Impact
Co-Workers
Citizens Sustaining Potential Psychological Impact
Witnesses
Citizens Sustaining Potential Psychological Impact
Distressed Citizens Far from Scene
Citizens Sustaining Potential Psychological Impact
Disaster Emergency Workers
Psychological Casualties from Disasters
and Acts of Terrorism
Category
DisasterDistant
Affected
Community
Community
Direct Impact--Injured
X
Direct Impact—Displaced
X
Direct Impact—Property Damage
On-scene Witnesses
Family Members
Friends
Co-Workers
Disaster Emergency Workers
X
X
X
X
X
X
X
X
X
X
No one
who experiences
a disaster is
untouched by it.
Psychological vs.
Medical
“Footprint”
Psychological vs. Medical “Footprint”
The size of
the
psychological
“footprint”
greatly
exceeds the
size of the
medical
“footprint”
psychological
“footprint”
medical
“footprint”
Case 1: Chemical Weapons
Site: Israel, Gulf War, 1991
Perpetrator: Iraq
Agent: Scud missiles with
possible poison gas payload
Scud Missile Attack, Israel, 1991
Case 1
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January 18 - February 28, 1991
23 missiles attack alerts
5 false alarms
1,059 ER visits
234 direct casualties (22%)
825 behavioral and psychological
casualties (78%)
 Psychological:Medical = 3.5:1
Source: Karsenty et al. 1991
Scud Missile Attack, Israel, 1991
Case 1
Suffered acute
anxiety: 544
Auto-injected
atropine without
exposure to the
agent: 230
Died: 11
 7 suffocated in their gas masks
 4 fatal heart attacks
Injured while
running to sealed
rooms: 40
Source: Karsenty et al. 1991
Case 1
Scud Missile Attack, Israel, 1991
Lessons learned
 More fatalities were
from fear behaviors
than from missile
impact.
 More hospitalizations
were for
psychological
responses than for
medical injury.
psychological
“footprint”
medical
“footprint”
Case 2: Chemical Weapons
Site: Toyko Subway, 1995
Perpetrator: Aum Shinrikyo cult
Agent: Sarin Gas
Sarin Attack, Tokyo, 1995
Case 2
 May 20, 1995: Monday
morning rush hour
 Simultaneous, multipoint attack
 Sarin placed on 5
trains converging on
central Tokyo
 15 stations affected
 Major focal point:
Kasumagaseki station
Source: Olson, 1999
Sarin Attack, Tokyo, 1995
 5,510 treated in 280
medical facilities
 1,046 admitted to
98 facilities
 134 responders
among the injured
 12 deaths
 >4,000 had no medical
signs of injury or exposure
 Psychological:medical = >4:1
Case 2
Sarin Attack in Tokyo Subway
Case 2
Examined and
discharged:
4023
Hospitalized: 984
Severely
injured: 62
Killed 12
Source: Norwood, 2002
Sarin Attack, Tokyo, 1995
Lesson learned
Case 2
Psychological casualties outnumbered
medical casualties.
psychological
“footprint”
medical
“footprint”
Stressors
at the
Crisis Scene
Stressors
Events or situations
that produce
physical or
psychological
reactions
Stressors
Stressors can be:
Real or Imagined
Internal or External
Absolute or Perceived
Stress is related to the
absolute magnitude of
the stressor and the
person’s perception of
the stressor
Threat of Terrorism and Mental Health:
A Public Opinion Poll
The primary goal of a terrorist attack
is to create fear and distress:
Strongly agree: 69%
Agree:
24%
Total:
93%
Source: National Mental Health Association (NMHA)
National Association of State Mental Health Program Directors (NASMHPD)
Widmeyer Communications, 2004
Threat of Terrorism and Mental Health:
A Public Opinion Poll
The threat of terrorism, by itself,
creates public fear and distress:
Strongly agree: 44%
Agree:
44%
Total:
88%
Source: National Mental Health Association (NMHA)
National Association of State Mental Health Program Directors (NASMHPD)
Widmeyer Communications, 2004
Disaster Stressors
“Perfect Storm”
of terrorism
characteristics:
 Unpredictable
 Uncontrollable
 Unfamiliar
 Unrelenting
Disaster Stressors
 Exposure to traumatic
event
 Encounter with death
and destruction
 Grotesque scenes
 Injury to self or loved
ones
 Noxious agents
Disaster Stressors
 Loss or separation
from loved ones
 Loss of home
 Loss of valued
possessions
 Lack of information
Reactions at the
Crisis Scene
Reactions at the Crisis Scene
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Fight or flight or freeze response
Escape and survival behaviors
Search and rescue behaviors
Public fear responses
Possible: Contagion of fear
Possible: Panic behaviors
Fight or Flight or Freeze Response
Major behavioral goal  SURVIVAL
Activate vital functions to fight or flee:
 Autonomic nervous system
 Heart and lungs
 Muscles of the extremities
 Energy mobilization
 Brainstem mental activity
We react to
stress 5 ways
Physical
Emotional
Cognitive
Spiritual
Behavioral
Immediate Responses
 Increased heart rate,
blood pressure,
respiration
 Gastrointestinal
distress-nausea
 Sweating, shivering
 Dizziness
 Muscle tremors,
weakness
Physical
Immediate Responses
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Shock
Numbness
Fear
Terror
Feeling unreal
Feeling out of control
Disorientation
Rapidly-shifting emotions
Emotional numbing
Emotional
Immediate Responses
 Confusion
 Time distortion
 Difficulty making
decisions
 Intrusive images of the
disaster
 Change in awareness
of one’s surroundings
Cognitive
Immediate Responses
 Intense use of prayer
 Reliance on faith
Spiritual
Immediate Responses
Behavioral
Responses to crisis can be:
 Functional vs. nonfunctional
 Life-saving vs. life-threatening
 Health-promoting vs.
Health-compromising
Behavior Change
Fear and Distress
Threat or
perception
of threat
Positive/
Adaptive
Behavior
Negative/
Maladaptive
Behavior
Immediate Responses
Behavioral
Concerned citizens may attempt to:
 Go home
 Go to schools to pick up children
 Hit the road, trying to escape the area
A subset of concerned citizens will:
 Go to Emergency Departments
 Go to hospitals
Immediate Responses Behavioral
Public fear may:
 Block highways
 Cause more casualties
 Disrupt emergency
response
Public fear may:
 Overwhelm hospitals
 Overwhelm ERs
 Exceed “surge capacity”
Bioterrorism:
A Special Case
Bioterrorism:
Defining Elements of a Bioterrorism Event
Undetectable by human senses +
Prolonged incubation period +
Limited surveillance capability =
Unrecognized exposure
Bioterrorism:
Psychological Impact
 Fear of contagion-- family & community
 Fear of treatment unavailability
 Fear of quarantine
 Fear of death
 Fear of grotesque
disease symptoms
 Misinterpretation of
anxiety symptoms as signs of infection
Bioterrorism:
Behavioral Reactions
 High-volume demand for medical
attention
 High-volume demand for screening
 Fear-driven evacuation
 Hoarding of medications
 Competition for scarce medical care
 Self-isolation or self-quarantine
Bioterrorism:
Behavioral Consequences
“We have Cipro…”
Source: BBC News, Monday, 22 October, 2001
Phases of Community
Response to Disaster
Community Behavioral Health by Disaster Phase
Pre-disaster
Disaster
Post-disaster
COMMUNITY
SOLIDARITY
IMPACT
Days
Years
The majority of
persons exposed to a
disaster return to
normal functioning.
Resilience
is the rule.
The “mantra”
of disaster behavioral health :
The event is abnormal,
not the individual’s response.
Impact Phase
 Duration:
Impact period
 Plans activated
 Survival behaviors
 Responses:
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Shock
Terror
Fear
“Stun” reaction
Freeze reaction
Heroic Phase
 Duration:
Hours to few days
 Behaviors:
 Seeking safety
 Search
 Rescue
 Aid
Heroic Phase
 Altruism is
common
 Self-assessment
of risk may be
distorted
 Separation from
family members
is distressing
Community Solidarity Phase
 Duration: weeks to
months
 Survivor optimism
 Gratitude for survival
 Community solidarity
 Bonding
 Community acts to
protect survivors
Community Solidarity Phase
 Assistance pours
into the area
 Media focuses on
event
 Belief that life will
rapidly return to
normal
Disillusionment Phase
 Duration: months to years
 Fatigue emerges
 Losses are realistically assessed
Disillusionment Phase
 Media pulls out
 Volunteerism declines
 Persons remain
displaced
 Hope diminishes
 Resentment builds
 Community cohesion is
challenged
Reconstruction Phase
 Duration: months
to years
 Rebuilding
continues
 The new reality is
accepted
 Anniversaries or
reminders may be
distressing
Reconstruction Phase
 Renewed
appreciation for life
and relationships
 Reassessment of
priorities and
commitments
 Recognition of
personal strengths
Reconstruction Phase
Recovery process
for survivors is
highly variable:
 Most regain
predisaster level of
functioning
 Some emerge at a
higher level of
functioning
Public Fear and
Panic Behavior
In a disaster
or terrorist attack,
citizens will be fearful,
but panic probably
will not occur.
What is Mass Panic ?
Group phenomenon in which
intense, contagious fear
causes individuals only to think
of themselves, causing harm to
others as they act to save
themselves.
Source: Ursano et al., 2003; Shultz, 2004
Mass Panic
 Panic is rare following disasters
 Panic did not occur during:
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Israeli Scud attacks
Tokyo sarin gas attack
Oklahoma City bombing
Evacuation of World Trade Center
 Risk is reduced by providing accurate
information—even if it is not good news
 Training and simulation decrease risk
Source: Locke, 2002
Risk factors for Panic
 Belief there is only a
small chance for
escape
 Perceived high risk
 Perceived high
likelihood of death
 Surprise
 Novelty
Source: Ursano et al., 2003
“The Station” Nightclub Fire
West Warwick, Rhode Island,
February 21, 2003
Public Fear Behaviors
JCAHO Recommends:
Directly address fear created by terrorism
through:
 Targeted education
 Application of risk reduction strategies
 Teaching coping skills
Source: JCAHO, 2003
Public Fear and
Hospital Surge
Fear,
with or without panic,
will bring large
numbers of citizens
to hospitals.
The majority of persons exposed to disaster
experience fear and distress at the time of
impact.
Fear and Distress
Response
Impact of
Disaster
Event
Most will not
come to hospitals.
A subset will be distressed to the point
of significant behavior change.
Fear and Distress
Response
Impact of
Disaster
Event
Behavior
Change
Many will seek care
at hospitals.
Only a small subset progress to
psychiatric illness.
Fear and Distress
Response
Impact of
Disaster
Event
Behavior
Change
Psychiatric
Illness
Many will need care
later at hospitals.
Hospital Utilization by Disaster Phase
Pre-disaster
Disaster
Post-disaster
COMMUNITY
SOLIDARITY
IMPACT
Medical
Psychological
Days
Years
Disaster Behavioral
Health Training
Disaster Behavioral Health
Hospitals have not developed
plans and protocols
for dealing with
disaster behavioral health issues
during crises and extreme events.
Disaster Behavioral Health Training
We will present
behavioral health strategies
from the perspective
of three roles for hospitals:
1. Hospital as Patient Care Provider
2. Hospital as Workplace
3. Hospital as Community Partner
Hospital as a Patient
Care Provider
Patients
Hospital
Community
Staff
Hospital as a
Community Partner
Hospital as a
Workplace
Disaster Behavioral Health Planning
We will present
behavioral health strategies
in a structure and format
that can be translated
into strategic planning.
Disaster Behavioral Health Planning
Planning uses two key dimensions:
• Disaster phase
• Pre-event
• Event
• Post-event
• Hospital roles
• Hospital as a Patient Care Provider
• Hospital as a Workplace
• Hospital as a Community Partner
Activities by Disaster Phase
Pre-event
 Plan
 Train
 Conduct drills
 Evaluate preparedness
Event
 Activate and implement
Post-event  Restore function
 Evaluate performance
Patient Care
Strategies
Expand surge capacity
Conduct behavioral triage
Conduct behavioral
intervention
Manage contamination,
isolation, and quarantine
Maintain quality patient care
Support patient families
Meet special population
needs
Provide culturally-competent
care
Communicate with the public
Plan
Prepare & Mitigate
Respond
Recover
Pre-event
Event
Post-event
Train
Drill
Evaluate
Activate
Restore
Evaluate
Workplace
Strategies
Provide staff protection and
safety
Expand staffing to meet
patient surge demands
Provide personnel support
Encourage behavioral selfcare
Plan
Prepare & Mitigate
Respond
Recover
Pre-event
Event
Post-event
Train
Drill
Evaluate
Activate
Restore
Evaluate
Community
Partner Strategies
Prepare health care system
for behavioral consequences
of terrorism
Prepare community to
respond to public fear
Plan
Prepare & Mitigate
Respond
Recover
Pre-event
Event
Post-event
Train
Drill
Evaluate
Activate
Restore
Evaluate