大愛醫療無國界 Delivery of Medical Care in Natural Disaster

1. 大愛醫療無國界Delivery of Medical Care in Natural Disaster 大林慈濟醫院 李維哲 醫師 Buddhist Dalin TzuChi General Hospital Wei-che Lee MD

2. Basic Disaster Awareness • Disasters follow no rules. No one can predict the complexity, time, or location of the next disaster. • All disasters, regardless of etiology, have similar medical and public health consequences. • Disasters differ in the degree to which these consequences occur and the degree to which they disrupt the medical and public health infrastructure of the disaster scene.

3. Basic Disaster Awareness • The key principle of disaster care is To Do the Greatest Good for the Greatest Number of Patients, while the objective of conventional medical care is to do the greatest good for the individual patient. • Mass Casualty Incident (MCI) Response.A consistent approach to disasters, based on an understanding of their common features and the response expertise they require.

4. Basic Disaster Awareness • The mass-casualty-incident response has four critical medical components: Search and rescue Triage and initial stabilization Definitive medical care Evacuation • This strategy permits teams from various countries to work together to meet disaster-related needs, despite language and cultural barriers.

5. Basic Disaster Awareness • Disaster Medicine is a severe form of First Aid, in which treatment priorities need to be reassessed against those usually applied in an everyday First Aid emergency. • Priorities are reassessed because:Significant numbers of casualties are involved Emergency services are overwhelmed Hospital facilities are compromised Damaged roads mean difficulties with transportation.

6. TIMA in Natural Disaster • El Salvador, Jan 13, 2001 • 7.6-magnitude earthquake struck El Salvador at 11:34 AM, killing at least 844, injuring 4,723 and damaging or destroying 278,000 dwellings.

7. El Salvador, Jan 13, 2001 • Exactly one month later another quake, with a magnitude of 6.6, hit this country, killing at least 400, injuring 3,153 and destroying 45,000 homes. Still recovering from the damage wrought by Hurricane Mitch few years ago, this disaster maimed the tiny country.

8. TIMA in Natural Disaster • El Salvador, Jan 13, 2001 • The first Tzu Chi medical team, composed of five physicians and one nurse from the United States, provided medical service for some 2,000 residents at four places in three days. • Tzu Chi distributed food for 35,750 victims to last one month and helped 6,729 victims through the free clinics.

9. TIMA in Natural Disaster • Back to 921 Earthquake • 921 earthquake rocked the island at 1:47 am. By 3am, TzuChi Taichung Rescue Center was established. • TIMA members established first aids stations in 11 heavily damaged areas • Medical teams from Tzu Chi Hospital in Hualien, consisted of 40 medical staffs, set up medical aids centers in 3 local hospitals.

10. TIMA in Natural Disaster • Iran Earthquake, Dec 26, 2003 • 41,000 people presumed to be dead • Tens of thousands injured • Nearly all survivors among the original 100,000 inhabitants left homeless.

11. Iran Earthquake, Dec 26, 2003

12. TIMA in Natural Disaster • Iran Earthquake, Dec 26, 2003 • Medical aid is not simply coming to the help of someone in pain, but should also inspire local people to bring their own compassion and kindness into play, so that even more people will contribute.

13. TIMA in Natural Disaster

14. Principles of International Relief Work • Directness: We insist on personally distributing relief supplies into the hands of victims without going through any third party. • Priority: There are too many victims and disasters in the world, and our resources are very limited. So we are forced to offer our help and rebuild homes only for victims in the most devastated areas. • Respect: We respect the victims' lifestyles, customs, culture and traditions. We distribute relief supplies with gratitude and without expecting to receive anything in return, so that the victims' dignity will be maintained.

15. Principles of International Relief Work • Timeliness: We provide victims with what they need when they need it the most. Though our resources are limited, their hearts will be warmed. • Conservation: We fully utilize every single dollar that people have donated. "Three No's" principles during relief distribution: • No politics • No propaganda • No religion, especially in mainland china.

16. Notes on International Relief Work • Medical intelligence is an essential part of an international disaster response. • Data on endemic and epidemic illnesses are critical, but an understanding of the cultural and social norms is of equal importance in meeting disaster-related needs. • Trained specialists, however well-intentioned, do not by themselves constitute an effective medical team for a response to international disasters. • Critical to a successful medical response to a mass casualty incident are important non-medical elements such as communication, safety, sanitation, and security.

17. Acute Injuries and Illnesses in the Aftermath of a Natural Disaster • Open and closed fractures • Foreign-body eye injuries • Crush-related injury and contaminated lacerations • Drowning • Heart attacks and other stress- and exertion-related conditions • Injury and exacerbation of illness related to the evacuation and transferring • Electrocutions • Shock

18. Disruption of Medical and Public Health Infrastructure • Local clinics • Drugstores • Hemodialysis center • Psycotherapy service • Home care nursing • IV medication • Parenteral nutrition • Ventilator • Dialysis • Oxygen

19. Needs Of The VictimsDuring the Immediate Phase Whether they are injured, survivors, disaster victims, evacuees or people involved, the victims all have the same needs:

20. Needs Of The VictimsDuring the Immediate Phase Physical Needs • Survival • To be looked after (somatic care and medico-psychological care) • Shelter (tent, gymnasium, caravan, housing) • Bedding (bed, blankets) • Food and drink • Hygiene (washing, toilets) • Clothing, grants

21. Needs Of The VictimsDuring the Immediate Phase Cognitive needs • Information (about the disaster) • Information on aid, help and grants • Information on legal advice

22. Needs Of The VictimsDuring the Immediate Phase Emotional needs • Need not to feel abandoned or excluded • Need to verbalize the experience lived through • Need to be listened to • Need for empathy and understanding • Need to return to (or be accepted in) the community of the living • Need to restore autonomy

23. Disaster Medical Assistant Team (DMAT) DMAT teams normally consist of approximately 35 members – • 4 or 5 physicians • 10 to 12 nurses and paramedics • 8 to 12 EMTs • The remainder of the team made up of support personnel There are still controversies about role of the volunteers attending in the DMATs. • Most of the volunteers lack in medical training such as basic and advanced life support and lack clinical experiences.

24. Disaster Medical Assistant Team (DMAT) • Deploy to disaster sites with sufficient supplies and equipment to sustain themselves for a period of 72 hours while providing medical care at a fixed or temporary medical care site. • In mass casualty incidents, Triaging patients Providing austere medical care Preparing patients for evacuation • May provide primary health care and/or may serve to augment overloaded local health care staffs.

25. Disaster Medical Assistant Team (DMAT) • DMAT is an independent, self-sufficient team that can be deployed within a matter of hours and can set up and continue operations at the disaster site for up to 72 hours with no additional supplies or personnel. • The 72-hour period allows national/international support, including medical supplies, food, water and any other commodity required by the DMAT, to arrive.

26. Operations Plan of the Medical Disaster-response • The model organizes surviving health care providers into teams capable of delivering medical care immediately. • Stabilize the condition of victims in the field and then facilitate their transport. • The plan is divided into three phases according to the time elapsed and the location of treatment:Hour 0 to 1 Solo-treatment periodHours 1 to 12 Disaster-medical-aid periodHours 12 to 72 Casualty-collection period.

27. Phase 1: Solo-Treatment Areas • Immediately after an earthquake, physicians would assess their surroundings. • If patients in critical condition were present, solo-treatment locations would be established where patients could be evaluated and their condition stabilized with resources from a medical backpack. • Patients would be moved to a disaster-medical-aid center as soon as possible.

28. Medical Emergencies and First Aid • Most field medical situations you encounter are not immediately life threatening. The few that are can generally be addressed by anyone with basic first aid skills and a rational approach. • Maintain a calm, thoughtful manner. Panic will cause or contribute to a “shock” response in the victim and may cause others to act irrationally as well.

29. Medical Emergencies and First Aid • When confronted by a medical emergency, your first step is to determine whether or not you can safely and effectively render assistance. • Do not move the victim unless you have to for your safety or his or hers. • Once you have determined that you are not endangering yourself and that the victim is in a relatively safe position, get help if you are able to do so.

30. Medical Emergencies and First Aid WARNING • There is a definite risk to the first aid responder from the bodily fluids of the patient. These include blood, mucus, urine, and other secretions. • You should take the steps necessary to protect yourself before attempting to treat the patient. • Use surgical gloves if you have them. Also, it is strongly advised that you use a cardiopulmonary resuscitation (CPR) barrier device if giving mouth to mouth. • A facemask will also reduce the potential for rescuer infection.

31. Medical Emergencies and First Aid Try to do the most good for the greatest number in the shortest possible time but always ensure your own safety first! • Do not attempt CPR (heart massage) unless you have received instruction in the technique. • Do not give a casualty any food or drink if they are badly injured, suspected of having broken bones, or are likely to require surgical treatment.

32. Medical Emergencies and First Aid

33. Medical Emergencies and First Aid Primary Survey • Ensure your own safety first. • Assess the hazards and remove or secure them where possible. • Sort mobile casualties from immobile ones. • Assess the consciousness of any silent, immobile casualties by use of voice and/or tapping collarbone.

34. Medical Emergencies and First Aid Primary Survey • Use your voice first - "Can you hear me?". • If casualty responds, place in a comfortable position and monitor. • If casualty does not respond, tap their collarbone to check response to pain. • If casualty responds to tap, place in recovery position and arrange transfer to hospital.

35. Medical Emergencies and First Aid Primary Survey • If patient does not respond, assess their breathing and circulation. • If breathing and pulse detected, place in recovery position, cover and arrange urgent transfer to hospital (advanced life support facility). • Where there are many casualties, if there is no breathing or pulse, move on to others.

36. Phase 2: Disaster-Medical-Aid Centers • Evenly spaced in a community, set up no more than an hour's walk from any location even if the transportation system failed. • 3 physicians per site to provide coverage for alternating 12-hour shifts and 1 backup. • Sites might include schools, fire stations, and hospitals. • Adjacent open area to serve as a helicopter landing zone for patient evacuation and the resupply of equipment.

37. Medical-aid Centers • The principal sites for the delivery of medical care. • An initial triage area immediately outside the center, in accordance with the Simple Triage and Rapid Treatment system • The walking wounded would be identified first. • The remaining patients would then be divided into three categories:Those requiring immediate care Those for whom care might be delayed The dead or dying

39. Medical-aid Centers • Patients assigned to the immediate-care and delayed-care categories would receive further evaluation and treatment. • The dead would be sent to the morgue area and those facing imminent death segregated. • The walking wounded might be used as volunteers to assist health care workers. • Patients would be periodically reevaluated.

40. Medical-aid Centers

41. Medical-aid Centers

42. Medical-aid Centers

43. Phase 3: Casualty-Collection Points • Performs two functions: • First, it serves as a staging area for the arrival of medical supplies and personnel and the evacuation of patients. • Second, it contains a medical area for triage and treatment. • Once stabilized, patients would be transported either to newly established field hospitals or to functioning hospitals outside the disaster zone.

44. Casualty Collection Sites Casualty collection sites for Levels 1 and 2 triage should be located close enough to a disaster site to offer quick treatment, but far enough away to be safe. Important features are: • Proximity to the disaster site • Safety from hazards and upwind location from contaminated environments • Protection from climactic conditions • Easy visibility for disaster victims • Convenient exit routes for air and land evacuation

45. Follow-up Trauma and Medical Care • >first 48 hours,the health services progressively overwhelmed by the need for secondary or maintenance care for the trauma victims as well as the demand resulting from the rapid emergence of normal emergencies or routine medical care. • The health facilities may not be fully operational and staff will urgently need some rest and time to care for possible personal losses.

46. Long-term Medical Sequelae of Natural Disasters • Clean-up and rebuilding-related injury • Food- and water-borne disease • Carbon monoxide (CO) poisoning with gasoline-powered electricity generators • Snake and rodents bite • Arboviral infection

47. Common Diseases • The most common symptoms and diseases among displaced people are those normally to be expected in a developing country: Diarrhea Measles Nutrition Deficiencies Respiratory Infections Malaria Parasites Anemia. • However, crowded conditions among the displaced people are likely to increase the occurrence of these diseases, in particular diarrhea.

49. Long-term Medical Sequelae • Diarrhea, due to the new environment, overcrowding, and poor environmental services, usually poses the major threat to displaced people’s health in the first weeks of living in a camp. • It remains a major health risk should there be a sudden deterioration in some aspect of the communal services, such as contamination of the water supply.

50. Long-term Medical Sequelae • An important point to note is that among the diseases listed, 80- 90% of all deaths in displaced populations are caused by five killer conditions: Malnutrition Measles Acute Respiratory Infections Diarrheal Diseases Malaria. • Most of these diseases are caused byprotozoa, bacteria, or viruses.