INTRODUCTION prevent or manage the way, people and their communities

respond to disaster. So, nurses have an important role to

“Doing the best for the most, with the least, by the fewest”
play during a disaster to save the lives and to provide
Disasters have been integral parts of the human experience healthcare to the victims.
since the beginning of time, causing premature death,
DEFINITIONS
impaired quality of life, and altered health status. The risk of
a disaster is ubiquitous. On average, one disaster per week Disaster is a result of vast ecological breakdown in the
that requires international assistance occurs somewhere in relation between humans and their environment, as serious
the world. The recent dramatic increase in natural disasters, or sudden event on such scale that the stricken community
their intensity, the number of people affected by them, and needs extraordinary efforts to cope with outside help or
the human and economic losses associated with these international aid.
events have placed an imperative on disaster planning for
WHO defines Disaster as "any occurrence that causes
emergency preparedness. Global warming, shifts in
damage, ecological disruption, loss of human life,
climates, sea-level rise, and societal factors may coalesce
deterioration of health and health services, on a scale
to create future calamities. Finally, war, acts of aggression,
sufficient to warrant an extraordinary response from outside
and the incidence of terrorist attacks are reminder of the
the affected community or area."
potentially deadly consequences of man’s inhumanity
toward man. Red Cross (1975) defines Disaster as “An occurrence such
as hurricane, tornado,  storm, flood, high water, wind-driven
The word derives from French “désastre” and that from Old
water, tidal wave, earthquake, drought, blizzard, pestilence,
Italian “disastro”, which in turn comes from the Greek
famine, fire, explosion, building collapse, transportation
pejorative prefix dus = "bad" + aster = "star". The root of the
wreck, or other situation that causes human suffering or
word disaster ("bad star" in Greek) comes from an
creates human that the victims cannot alleviate without
astrological theme in which the ancients used to refer to the
assistance.”
destruction or deconstruction of a star as a disaster. The
ancient people believed that the disaster is occurred due to UNDP (2004) defines “Disaster is a serious disruption
the unfavourable position of the “planets” or “Act of God”. triggered by a hazard, causing human, material, economic
Gradually they understand the mysteries of nature. or (and) environmental losses, which exceed the ability of
those affected to cope.”
Disaster has many forms, which can affect one family at a
time, as in a house fire, or it can affect a city in case of Disaster can be defined as “Any catastrophic situation in
chemical leak in Bhopal (Dec 2-3, 1984) kill 2500 and which the normal patterns of life (or ecosystems) have been
injured 150,000 or affect a state in case of Gujarat disrupted and extraordinary, emergency interventions are
earthquake (Jan 26, 2001) affect 21 districts out of 25 required to save and preserve human lives and/or the
districts of the state of Gujarat. 4 major urban area (Bhuj, environment.”
Anjar, Bachau and Rapar) and 450 villages are almost near
to totally destroyed. There were more than 20,000 death Disaster may also be termed as “a serious disruption of the
and 167,000 people were injured 600,000 people are functioning of society, causing widespread human, material
homeless. or environmental losses which exceed the ability of the
affected society to cope using its own resources.”
India has been traditionally vulnerable to natural disasters
on account of its unique geo-climatic conditions. Floods, Thus, a disaster may have the following main features:-
droughts, cyclones, earthquakes and landslides have been · Unpredictability
recurrent phenomena. About 60% of the landmass is prone · Unfamiliarity
to earthquakes of various intensities; over 40 million · Speed
hectares is prone to floods; about 8% of the total area is · Urgency
prone to cyclones and 68% of the area is susceptible to · Uncertainty
drought. · Threat
We do not expect disaster, but they happen with living, TYPES OF DISASTER
come natural calamities, the individual and technological
advances, come from expedient, socio-economic and Disasters are classified in various ways, on the basis of its
political stagnation and war etc. disaster either man-made origin/cause.
or natural, may be inevitable, but there are methods to
 1. Natural disasters ·         Environmental Degradation - Processes induced by
2. Man-made disasters human behaviors and activities that damage the natural
resources base on adversely alter nature processes or
And on the basis of speed of onset-
ecosystems. Potentials effects are varied and may
1. Sudden onset disasters contribute to the increase in vulnerability, frequency and the
2. Slow onset disasters intensity of natural hazards. Examples include land
degradation, deforestation, desertification, wild land fire,
NATURAL DISASTERS loss of biodiversity, land, water and air pollution climate
A serious disruption triggered by a natural hazard (hydro- change, sea level rise and ozone depletion.
metrological, geological or biological in origin) causing LEVELS OF DISASTER
human, material, economic or environmental losses, which
exceed the ability of those affected to cope. Natural Goolsby and Kulkarni (2006) further classify disasters
hazards can be classified according to their (1) hydro according to the magnitude of the disaster in relation to the
meteorological, (2) geological or (3) biological origins. ability of the agency or community to respond. Disasters
are classified by the following levels:
·         Hydrometer logical disaster  - Natural processes or
phenomena of atmospheric hydrological or oceanographic 1)      Level I: If the organization, agency, or community is
nature. Phenomena / Examples - Cyclones, typhoons, able to contain the event and respond effectively utilizing its
hurricanes, tornados, Storms, hailstorms, snowstorms, cold own resources.
spells, heat waves and droughts.
2)      Level II: If the disaster requires assistance from
·         Geographical disaster - Natural earth processes or external sources, but these can be obtained from nearby
phenomena that include processes of endogenous origin or agencies.
tectonic or exogenous origin such as mass movements,
3)      Level III: If the disaster is of a magnitude that exceeds
Permafrost, snow avalanches. Phenomena / Examples -
the capacity of the local community or region and requires
Earthquake, tsunami, volcanic activity, Mass movements
assistance from state-level or even federal assets.
landslides, Surface collapse, geographical fault activities
etc. KEY ELEMENTS OF DISASTERS
·         Biological Disaster - Processes of organic organs or Disasters result from the combination of hazards, conditions
those conveyed by biological vectors, including exposure to of vulnerability and insufficient capacity or measures to
pathogenic, microorganism, toxins and bioactive reduce the potential negative consequences of risk.
substances. Phenomena / Examples - Outbreaks of
Hazards
epidemics Diseases, plant or animal contagion and
extensive infestation etc. Hazards are defined as “Phenomena that pose a threat to
people, structures, or economic assets and which may
HUMAN-INDUCED DISASTERS
cause a disaster. They could be either manmade or
A serious disruption triggered by a human-induced hazard naturally occurring in our environment.”
causing human, material, economic or environmental
Hazard is a potentially damaging physical event,
losses, which exceed the ability of those affected to cope.
phenomenon or human activity that may cause the loss of
These can be classified into – (1) Technological Disaster
life or injury, property damage, social and economic
and (2) Environmental Degradation.
disruption or environmental degradation. (UN ISDR 2002)
·         Technological disaster - Danger associated with
Vulnerability
technological or industrial accidents, infrastructure failures
or certain human activities which may cause the loss of life Vulnerability is the condition determined by physical, social,
or injury, property damage, social or economic disruption or economic and environmental factors or processes, which
environmental degradation, sometimes referred to as increase the susceptibility of a community to the impact of
anthropological hazards. Examples include industrial hazards. (UN ISDR 2002)
pollution, nuclear release and radioactivity, toxic waste,
dam failure, transport industrial or technological accidents Capacity
(explosions fires spills). Capacity is the combination of all the strengths and
resources available within a community, society or
organization that can reduce the level of risk, or the effects 6. To respect cultural, lingual, and religious diversity
of a disaster. Capacity may include physical, institutional, in individuals and families and to apply this
social or economic means as well as skilled personal or principle in all health promotion activities.
collective attributes such as 'leadership' and 'management.' 7. To promote the highest achievable quality of life
Capacity may also be described as capability. (UN ISDR for survivors.
2002)
PRINCIPLES OF DISASTER NURSING
Risk
The basic principles of nursing during special (events)
Risk is the probability of harmful consequences, or circumstances and disaster conditions include:
expected losses (deaths, injuries, property, livelihoods,
1. Rapid assessment of the situation and of nursing
economic activity disrupted or environment damaged)
care needs.
resulting from interactions between natural or human-
2. Triage and initiation of life-saving measures first.
induced hazards and vulnerable conditions. (UNDP 2004)
3. The selected use of essential nursing
Risk is conventionally expressed by the equation: interventions and the elimination of nonessential
nursing activities.
Risk = Hazard x Vulnerability
4. Adaptation of necessary nursing skills to disaster
Some professionals use the notation: and other emergency situations. The nurse must
use imagination and resourcefulness in dealing
Risk = (Hazards x Vulnerability) - Capacity with a lack of supplies, equipment, and
They identify capacity as an element that can drastically personnel.
reduce the effects of hazards, and vulnerabilities and thus 5. Evaluation of the environment and the mitigation
reduce risk. or removal of any health hazards.
6. Prevention of further injury or illness.
For example, an earthquake hazard of the same magnitude 7. Leadership in coordinating patient triage, care,
in a sparsely populated village of Rajasthan and in the and transport during times of crisis.
densely populated city of Delhi will cause different levels of 8. The teaching, supervision, and utilization of
damage to human lives, property and economic activities. auxiliary medical personnel and volunteers.
9. Provision of understanding, compassion, and
DISASTER NURSING- DEFINITION
emotional support to all victims and their families.
Disaster nursing can be defined as “the adaptation of
HEALTH EFFECTS OF DISASTERS
professional nursing knowledge, skills and attitude in
recognizing and meeting the nursing, health and emotional The health effects of disasters may be extensive and broad
needs of disaster victims.” in their distribution across populations. In addition to
causing illness and injury, disasters disrupt access to
GOALS OF THE DISASTER NURSING
primary care and preventive services. Depending on the
The overall goal of disaster nursing is to achieve the best nature and location of the disaster, its effects on the short-
possible level of health for the people and the community and long-term health of a population may be difficult to
involved in the disaster. measure.

Other goals of disaster nursing are the following: Disasters affect the health status of a community in the
following ways: -
1. To meet the immediate basic survival needs of
populations affected by disasters (water, food, ·         Disasters may cause premature deaths, illnesses,
shelter, and security). and injuries in the affected community, generally exceeding
2. To identify the potential for a secondary disaster. the capacity of the local health care system.
3. To appraise both risks and resources in the
·         Disasters may destroy the local health care
environment.
infrastructure, which will therefore be unable to respond to
4. To correct inequalities in access to health care or
the emergency. Disruption of routine health care services
appropriate resources.
and prevention initiatives may lead to long-term
5. To empower survivors to participate in and
consequences in health outcomes in terms of increased
advocate for their own health and well-being.
morbidity and mortality.
·         Disasters may create environmental imbalances, The impact phase continues until the threat of further
increasing the risk of communicable diseases and destruction has passed and emergency plan is in effect.
environmental hazards. This is the time when the emergency operation center is
established and put in operation. It serves as the center for
·         Disasters may affect the psychological, emotional,
communication and other government agencies of health
and social well-being of the population in the affected
tears care healthcare providers to staff shelters. Every
community. Depending on the specific nature of the
shelter has a nurse as a member of disaster action team.
disaster, responses may range from fear, anxiety, and
The nurse is responsible for psychological support to
depression to widespread panic and terror.
victims in the shelter.
·         Disasters may cause shortages of food and cause
POST – IMPACT PHASE
severe nutritional deficiencies.
Recovery begins during the emergency phase and ends
·         Disasters may cause large population movements
with the return of normal community order and functioning.
(refugees) creating a burden on other health care systems
For persons in the impact area this phase may last a
and communities. Displaced populations and their host
lifetime (e.g. - victims of the atomic bomb of Hiroshima).
communities are at increased risk for communicable
The victims of  disaster in go through four stages of
diseases and the health consequences of crowded living
emotional response.
conditions.
1.      Denial - during the stage the victims may deny the
PHASES OF A DISASTER
magnitude of the problem or have not fully registered. The
There are three phases of disaster. victims may appear usually unconcerned.

1. Pre-Impact Phase 2.      Strong Emotional Response - in the second stage, the

person is aware of the problem but regards it as
2. Impact Phase overwhelming and unbearable. Common reaction during
3. Post – Impact Phase this stage is trembling, tightening of muscles, speaking with
the difficulty, weeping heightened, sensitivity, restlessness
PRE-IMPACT PHASE sadness, anger and passivity. The victim may want to retell
or relieve the disaster experience over and over.
It is the initial phase of disaster, prior to the actual
occurrence. A warning is given at the sign of the first 3.      Acceptance - During the third stage, the victim begins
possible danger to a community with the aid of weather to accept the problems caused by the disaster and makes a
networks and satellite many meteorological disasters can concentrated effect to solve them. It is important for victims
be predicted. to take specific action to help themselves and their families.
The earliest possible warning is crucial in preventing toss of 4.      Recovery - The fourth stage represent a recovery
life and minimizing damage. This is the period when the from the crisis reaction. Victims feel that they are back to
emergency preparedness plan is put into effect emergency normal. A sense of well-being is restored. Victims develop
centers are opened by the local civil, detention authority. the realistic memory of the experience.
Communication is a very important factor during this phase;
disaster personnel will call on amateur radio operators, DISASTER MANAGEMENT CYCLE
radio and television stations. THE DISASTER EVENT
The role of the nurse during this warning phase is to assist This refers to the real-time event of a hazard occurring and
in preparing shelters and emergency aid stations and affecting the ‘elements at risk’. The duration of the event will
establishing contact with other emergency service group. depend on the type of threat, for example, ground shaking
IMPACT PHASE may only occur for a few seconds during an earthquake
while flooding may take place over a longer period of time.
The impact phase occurs when the disaster actually
happens. It is a time of enduring hardship or injury end of There are five basic phases to a disaster management
trying to survive. cycle (Kim & Proctor, 2002), and each phase has specific
activities associated with it.
The impact phase may last for several minutes (e.g. after
an earthquake, plane crash or explosion.) or for days or RESPONSE
weeks (eg in a flood, famine or epidemic).
The response phase is the actual implementation of the These are steps that are taken to lessen the impact of a
disaster plan. The best response plans use an incident disaster should one occur and can be considered as
command system, are relatively simple, are routinely prevention and risk reduction measures. Examples of
practiced, and are modified when improvements are mitigation activities include installing and maintaining
needed. Response activities need to be continually backup generator power to mitigate the effects of a power
monitored and adjusted to the changing situation. failure or cross training staff to perform other tasks to
maintain services during a staffing crisis that is due to a
Activities a hospital, healthcare system, or public health
weather emergency.
agency take immediately during, and after a disaster or
emergency occurs. PREPAREDNESS/RISK ASSESSMENT
RECOVERY Evaluate the facility’s vulnerabilities or propensity for
disasters. Issues to consider include: weather patterns;
Once the incident is over, the organization and staff needs
geographic location; expectations related to public events
to recover. Invariably, services have been disrupted and it
and gatherings; age, condition, and location of the facility;
takes time to return to routines. Recovery is usually easier
and industries in close proximity to the hospital (e.g.,
if, during the response, some of the staff have been
nuclear power plant or chemical factory).
assigned to maintain essential services while others were
assigned to the disaster response.
Activities undertaken by a community and its components
after an emergency or disaster to restore minimum services
and move towards long-term restoration.
·         Debris Removal
·         Care and Shelter
·         Damage Assessments
·         Funding Assistance

MANAGEMENT OF MASS CASUALTIES

Mass Casualty Management is a multi-sectorial
coordination system based on daily utilized procedures,
managed by skilled personnel in order to maximize the use
of existing resources; provide prompt and adapted care to
the victims; ensure emergency services and hospital return
to routine operations as soon as possible.
EVALUATION/DEVELOPMENT
OBJECTIVES
Often this phase of disaster planning and response
·         The application of triage and tagging procedures in
receives the least attention. After a disaster, employees and
the management of mass casualties
the community are anxious to return to usual operations. It
is essential that a formal evaluation be done to determine ·         Understand the priorities in triage and tagging, and
what went well (what really worked) and what problems orders of evacuation
were identified. A specific individual should be charged with
the evaluation and follow-through activities. DISASTER TRIAGE

MITIGATION The word triage is derived from the French word trier, which
means, “to sort out or choose.”
The Baron Dominique Jean Larrey, who was the Chief TYPES OF TRIAGE
Surgeon for Napoleon, is credited with organizing the first
There are two types of triage:
triage system.
1.      Simple triage
“Triage is a process which places the right patient in the
right place at the right time to receive the right level of care” 2.      Advanced triage
(Rice & Abel, 1992).
SIMPLE TRIAGE
Triage is the process of prioritizing which patients are to be
treated first and is the cornerstone of good disaster Simple triage is used in a scene of mass casualty, in order
management in terms of judicious use of resources (Auf der to sort patients into those who need critical attention and
Heide, 2000). immediate transport to the hospital and those with less
serious injuries.
NEED OF THE DISASTER TRIAGE
This step can be started before transportation becomes
1. Inadequate resource to meet immediate needs available.
2. Infrastructure limitations
3. Inadequate hazard preparation The categorization of patients based on the severity of their
4. Limited transport capabilities injuries can be aided with the use of printed triage tags or
5. Multiple agencies responding colored flagging.
6. Hospital Resources Overwhelmed S.T.A.R.T. (Simple Triage and Rapid Treatment) is a simple
AIMS OF TRIAGE triage system that can be performed by lightly trained lay
and emergency personnel in emergencies.
1. To sort patients based on needs for immediate
care Triage separates the injured into four groups:
2. To recognize futility  0 - The deceased who are beyond help
3. Medical needs will outstrip the immediately
 1 - The injured who can be helped by immediate
available resources
transportation
4. Additional resources will become available given
 2 - The injured whose transport can be delayed
enough time.
 3 - Those with minor injuries, who need help less
PRINCIPLES OF TRIAGE urgently
The main principles of triage are as follows: - ADVANCED TRIAGE
1. Every patient should receive and triaged by In advanced triage, doctors may decide that some seriously
appropriate skilled health-care professionals. injured people should not receive advanced care because
2. Triage is a clinic-managerial decision and must they are unlikely to survive.
involve collaborative planning.
Advanced care will be used on patients with less severe
3. The triage process should not cause a delay in
the delivery of effective clinical care. injuries. Because treatment is intentionally withheld from
patients with certain injuries, advanced triage has an ethical
implication.
It is used to divert scarce resources away from patients with
little chance of survival in order to increase the chances of
ADVANTAGES OF TRIAGE
survival of others who are more likely to survive.
1. Helps to bring order and organization to a chaotic
Principles of advanced triage is
scene.
2. It identifies and provides care to those who are in ·         “Do the greatest good for the greatest number”
greatest need
3. Helps make the difficult decisions easier ·         Preservation of life takes precedence over
preservation of limbs.
4. Assure that resources are used in the most
effective manner ·         Immediate threats to life: HEMORRHAGE.
5. May take some of the emotional burden away
from those doing triage  
ADVANCED TRIAGE CATEGORIES “Dead or expected to die—massive head injury,
extensive full-thickness burns”
CLASS I
(EMERGENT)                  RED                      IMMEDIATE

– Victims with serious injuries that are life threatening but USING RPM TO CLASSIFY PATIENTS
has a high probability of survival if they received
immediate care. CATEGORY (COLOR) RPM INDICATORS

– They require immediate surgery or other life-saving Critical (RED) R = Respiratory rate >  30;
intervention, and have first priority for surgical teams or
P = Capillary refill >  2
transport to advanced facilities; they "cannot wait" but
seconds;
are likely to survive with immediate treatment.
M = Doesn’t obey
“Critical; life threatening—compromised airway, shock,
commands
hemorrhage”
CLASS II
(URGENT)                    YELLOW                                   D Urgent (YELLOW) R <  30
ELAYED P <  2 seconds
– Victims who are seriously injured and whose life is not M = Obeys commands
immediately threatened; and can delay transport and
treatment for 2 hours.
Expectant: dead or dying R = not breathing
– Their condition is stable for the moment but requires (BLACK)
watching by trained persons and frequent re-triage, will
need hospital care (and would receive immediate priority ROLE OF NURSING IN DISASTERS
care under "normal" circumstances).
“Disaster preparedness, including risk assessment and
“Major illness or injury;—open fracture, chest wound” multi-disciplinary management strategies at all system
levels, is critical to the delivery of effective responses to the
CLASS III (NON-URGENT)        short, medium, and long-term health needs of a disaster-
GREEN                                MINIMAL stricken population.” (International Council of Nurses, 2006)
– "Walking wounded," the casualty requires medical MAJOR ROLES OF NURSE IN DISASTERS
attention when all higher priority patients have been
evacuated, and may not require monitoring. 1. Determine magnitude of the event
2. Define health needs of the affected groups
– Patients/victims whose care and transport may be 3. Establish priorities and objectives
delayed 2 hours or more. 4. Identify actual and potential public health
problems
“minor injuries; walking wounded—closed fracture,
5. Determine resources needed to respond to the
sprain, strain”
needs identified
CLASS IV 6. Collaborate with other professional disciplines,
(EXPECTANT)           BLACK                    EXPECTANT governmental and non-governmental agencies
7. Maintain a unified chain of command
They are so severely injured that they will die of their 8. Communication
injuries, possibly in hours or days (large-body burns,
severe trauma, lethal radiation dose), or in life-
threatening medical crisis that they are unlikely to
DISASTER TIMELINE AND NURSING ACTION/
survive given the care available (cardiac arrest, septic
RESPONSIBILITIES
shock, severe head or chest wounds);
They should be taken to a holding area and given
painkillers as required to reduce suffering.
CONCLUSION
Disaster is an emergency situation where the need of the
victims mounts over the medical and nursing resources or
services particularly in the developing countries like India
where the resources are already short the situation
becomes worst; therefore coordination of actions and
various departments is an essential requisite for efficient
management of mass casualties. So, in such a scenario a
prudent nurse should be resourceful, making best use of
the available resources like governmental,
nongovernmental organizations, self-help groups, public,
etc. and should act ethically with best of her knowledge,
patience and judgement to minimize the effect of disaster.