Abstract
Working in a field hospital after manmade or nature disasters is a demanding mission, known to cause various physical and mental bad outcomes, from depression to post-traumatic stress disorder. The mental health professional (MHP) is critical for every field hospital and humanitarian missions. At the immediate aftermath of the trauma, his or her main mission is to help the other teams to cope with the sights and difficult decision making and, in later stages, the role is enlarged to helping the coping of disaster casualties as well as community leaders. The MHP’s part starts prior to leaving for the mission, with building the team’s resiliency, and ends weeks after coming back from the mission making sure no personnel suffers from secondary traumatization. The demands from the MHP varies when the mission is in high resources country versus low ones, with its differences on the hospital teams condition, urgency, and mental and physical load. Yet, he or she would always have a place in working with the teams during working hours and in a daily closure (through a modified debriefing), liaisons, and actual patient’s treatment, and that should be his or her main mission in field hospital activity.
Introduction
Any disaster – natural or human made – carries an urgent medical need. Most of the declared needs in the immediate aftermath of a mass trauma are physical, with surgical and orthopedic interventions in the immediate phase and medical problems with endemic epidemiological aspects in the next phase. Historically, the medical focus in disaster preparedness has been on injury, infection, and exposure related illness, but clinicians have been interested in postdisaster mental-health interventions since the 1940s[1].
Unlike physical injuries, adverse mental-health outcomes of disasters may not be apparent during the initial phases following the event, and therefore are often overlooked, but these mental outcomes due to exposure to a disaster are common. One-third or more of individuals severely exposed may develop posttraumatic stress disorder (PTSD) or other mental disorders – new or exacerbated. A systematic approach to the delivery of timely and appropriate disaster mental-health services may facilitate their integration into the emergency medical response[1,2] and improve their overall outcome. Among the mental disturbances, other than PTSD, the individuals might suffer from disorders such as adjustment disorder, major depression, and psychotic breakdown, as well as behavioral manifestations such as substance abuse, violence, helplessness, and suicidality.
The general society breakdown, personal and material losses, and physiological hardship (whether due to physical injury or to lack of food or shelter) make all the traumatic experiences severe and the chance of an unharmed long-term remission less probable.
Despite its severity, most victims of mass trauma tend to ignore the mental problem at first and most manifestations are those of the physical problems. As an example, during the post-tsunami medical care in Indonesia, evaluated at the Red Cross Hospital at Banda Aceh[2], the complaints were of the following: (1) urological (19%), (2) digestive (16%), (3) respiratory (12%), and (4) musculoskeletal (12%). Although < 2% of patients were diagnosed with a mental-health problem, 24% had at least four or more of the seven depression/PTSD symptoms addressed in the study[3].
The responders – professional and nonprofessional, working in humanitarian delegations and field hospitals – are also a community at risk for mental disorders. PTSD and depression were the most studied diagnoses with prevalence of PTSD ranging from 0% to 34% and depression from 21% to 53%[4]. The variations in the morbidity rate are due to under reporting as well as the way the responders were screened for the mission[5], escorted during the work, and looked after when it was over[6]. In a large review paper, most samples of rescue and recovery workers showed remarkable resilience. Within adult samples, more severe exposure, female gender, middle age, ethnic minority status, secondary stressors, prior psychiatric problems, and weak or deteriorating psychosocial resources most consistently increased the likelihood of adverse outcomes[7]. Psychiatric outcomes are not the only mental ramification of trauma. Symptoms and unpleasant emotions not qualifying as a psychiatric disorder are referred to as psychological distress. Distress, at some level, is nearly universal after disasters and is far more prevalent than psychiatric disorders. The distinction between these two entities is critical for effective disaster response because different interventions are needed for them[8].
When trying to understand the specific needs from the MHPs in the field hospital, one must understand that, unlike any other crew member, the team must provide assistance to the victims of the disaster-acute phase and long term – in the emergency room as well as in the liaisons work in the departments – but not less important to the team, in the preparedness, actual work, and after the return to safety, in the psychiatric and psychological aspects[7–9].
The integration of psychosocial care into emergency and medical disaster response must occur prior to the disaster itself, and will depend on effective collaboration between medical and mental-health-care providers[8,10].
In this chapter, we will try to conduct an overview of the mental factors crucial for the hospital members, the MHPs needed for the team and hospital work, other missions that should be proposed by those professionals in a humanitarian mission to the area’s population, and the basic screening and treating tools that should be implemented by them.
Field Hospital Team Care
The team must have as much knowledge as possible in regard to the nature of the disaster, the country’s state after the disaster, the mission ahead, its probable length, specific cultural aspects, and specific epidemiological data. The preparedness is different when arriving at safe grounds of a clean area, with no epidemiological threat, like an organized country after a single terrorist attack, and when arriving in a country like Haiti immediately after an earthquake.
At the basis of all procedures taken are the international and national conventions and laws. This implies that the medical assistance is adjunct to the local capabilities and requirements. The treatment should be accessible to all. Treatment should be customized to the traumatic arena while standing on the highest clinical standards of care possible given the limitations[11]. The psychological intervention schemes of treatment are multivariable. The first consideration is the exact nature of the disaster as opposed to the local remaining infrastructure and treating capabilities. The flow of decision is dictated by moral obligation. The psychosocial intervention schemes are multivariable, depending mainly on the exact nature of the disaster and the local remaining infrastructure and treatment capabilities. The decisions will be dictated by moral obligation. They will be discussed according to the different phases of the deployment: pre-deployment, during, and post-deployment.
Prior to the Mission
From the chapter authors’ experience, the three major reasons that people join an altruistic mission are as follows:
1. Leadership: Leadership in stressful situations should be as structured, concise, and trustworthy as possible. People need to feel that the commander is capable and reliable.
2. Camaraderie: The connection between people helps in building up courage. Team members are also willing to make sacrifices to help people they feel connected to. The strength of a group has been spoken of in literature, but its importance cannot be underestimated in a traumatic situation.
3. Meaning: The belief that there is something that is more important than themselves at this point of time. This can stem from ethics, religion, spirituality, beliefs, protecting of loved ones, and so on.
Therefore, the initial period while preparing for a mission should be dedicated to strengthening these three principles, and not “just” medical preparedness and equipment readiness.
The team members should meet before departure and engage in different, relevant missions such as preparing the gear for the mission and getting immunizations together. This enables the members to get to know each other on peaceful grounds and start feeling closer to each other before they feel tired and stressed. A team should be built with everyone knowing his or her specific role in the mission, and understanding that everybody has to take part in various combined missions such as erecting the hospital facility. Prior to leaving the country of origin, team members in the mission should be provided with information about the country they are going to and its condition after the trauma, and have people from past missions explaining what to expect. The main tool for this is psychoeducation and team building. This builds resiliency and puts the team at a better starting point for the mission. It is crucial to identify those not participating or those who tend to “cope by themselves.” It is common for the commanding officers of the mission not to take an active part in the team buildup since they have a lot to do at the organization stage. It is important the MHP makes sure the commanders use this time for team building as well. The MHP’s main focus at this point should be getting to know as many members of the team as possible. This includes members from all sectors: medical, paramedical, and logistic support personnel. They must attend as many team talks as possible as side participants, allowing the leadership team to lead the discussion, while taking part themselves. During these talks the MHP must ensure the participants understand that the MHP’s main role in the mission is to help them.
The ideal professional team should include a psychiatrist equipped with medicine and either a social worker or a psychologist. Both should be familiar with different methods for the treatment of acute stress disorder, as well as having the ability for group sessions and leading a debriefing group.
The drugs recommended for a mission like this should include benzodiazepine (BZ), sleeping pills, and major tranquilizing drugs such as olanzapine (tablets and injections). The role of BZ should be minimal as it is known to help in the acute phases, but enhances the incidence of PTSD later on. Selective serotonin reuptake inhibitor medications do not help in early phases; thus, their role is minimal. The specific amounts of medications should be decided prior to the mission according to the nature and location of the disaster and the anticipated length of stay.
The Early Phases of the Mission
This is a crucial phase for the success of the mission, as well as the psychological outcomes of the whole delegation. This can be divided into two major fields of action: (1) a country with poor infrastructure in a large disaster, with a mission adjacent to the disaster, for example Haiti, and (2) a country with a well-established infrastructure in a large disaster, with a mission adjacent to the disaster, for example Japan.
A Country with Poor Infrastructure
In general, rehabilitation after a traumatic event can take years. The outcome heavily depends on the general rehabilitation of the infrastructure at a local area. The aim in long-term rehabilitation is to build a narrative of “survivors” as opposed to “victims.” The empowerment of this shift in state of mind gives mastery and strength. What happened may be painful, but my choice is what I do with that pain and how it can help strengthen resilience, if implemented correctly. It is important to remember that, like any physical injury, the mind strives to repair itself. The MHP’s goal is to enable the psychological environment needed to empower the natural course of recovery. A mission in a country with poor infrastructure demands intensive work with the mission team and, if possible, with the local population to build their coping skills.
The MHP’s role with the emergency teams: The emergency teams do not tend to suffer from acute stress disorder nor any clinical sequelae. The teams are usually well prepared for the mission and have the necessary knowledge to fulfill their role.
Problems may arise in the early phase of the event in the following situations:
Physical needs are not met. It is important to work with the commander to make sure shifts allow for sufficient food, sleep, and safety. When the body is weak, people are more susceptible to primary, instinctual, and emotional types of thinking patterns, focusing on the primal brain. The attempt to avoid PTSD or other traumatic psychological sequelae is the enactment of the prefrontal cortex and executive functioning. It is hard to think “logically” when one is hungry. The physical needs of the team – food, toilet, and a place to sleep – are all crucial to their ability to continue functioning. These missions are a “marathon” of physical hardships, and every member must find a way to balance his or her needs and resources.
There is a big gap between the expected situation and that found on arrival. This can range from transportation problems to an overwhelming number of casualties with inadequate means to treat them. In this case, frustration and a feeling of helplessness can be detrimental to mental health. Frustration can also arise from other situations such as arriving to a “not-needed” scenario due to a paucity of casualties or an overabundance of local and foreign medical teams. It is important to abide by protocols and routine as much as possible. MHPs should encourage staff to share their difficulties with friends. Help the commander to phrase clear, precise, transparent, and hopeful messages to the staff.
Previous training does not fit the specific needs required in the situation. Help integrate staff members into other useful situations in accordance with their capabilities. Help to cognitively build a narrative of their tremendous contribution to the new situation, helping them to understand the cohesiveness of the team and that success is measured by the overall assistance. Stress that there are no “small” jobs and that everyone is needed exactly where they are for the mission to succeed.
The situation “hits home.” Trained as the medical team is, different chords become very personal at times. To function in a disaster arena, a healthy amount of detachment is needed. MHPs need to empathize; not sympathize. When “the wall” is broken for any reason (shock, similarity to loved ones, previous experience, and so on) it will “hit home” for the team member. Lead and pace the team member gently back to the professional discussion. This should be done gradually and thoughtfully, restoring the confidence, mastery, and professionalism to the team member.
Previous psychiatric problems are augmented or exacerbated by the physical or mental ordeal of the mission. In these situations, treat psychiatric problems as a psychiatrist would, taking into consideration: What do you have? How will it affect the team member? Side effects? The primary diagnosis and its implications on functioning? Always take into consideration lack of sleep as a major cause. If the psychiatric problem grows, consider evacuation home.
Physical problems causing psychiatric disorders. A psychiatrist in an emergency medical team (EMT) must always be mindful of the medical aspects in diagnosis and treatment. The overlap between hypoxia and acute stress reaction can be settled by a pulse oximeter.
The MHP’s role with the general population: The primary duty of an EMT is to understand the needs of the population and decide how the EMT can provide the best assistance to appropriately meet these needs.
Intervention in the population should involve working with local teachers, first responders, critical workers, and so on. This can have a secondary effect when these people work with wider circles of people in the population and alleviate suffering in a widespread manner. One must be familiar with the different stages societies may go through after a huge traumatic event.
Literature suggests that people and communities struck by disaster will generally go through four phases of response[11]:
1. Heroic phase: This first phase may begin prior to the event and last up to a week afterwards. People struggle to prevent loss of lives and they try to minimize property damage.
2. Honeymoon phase: The second phase may last from two weeks to two months. Massive relief efforts lift the spirits of survivors and hopes of a quick recovery run high, but optimism is often short lived.
3. Disillusionment phase: The disillusionment phase may last from several months to a year or more. Sometimes called the “second disaster,” the realities of bureaucratic paperwork and recovery delays set in, outside help leaves, and the local population realize they have a lot to do themselves.
4. Reconstruction phase: The final phase may take several years as normal functioning is gradually reestablished.
There may be a place for the MHP in taking care of psychiatric and psychological reactions. Among the victims, one might find exacerbation of mental-health disorders, new and old, such as psychotic attacks, dissociation, affective disorders, anxiety disorders, and even withdrawal from different addictions.
Related posts:
Chapter 6 – Training and Accreditation
Chapter 3 – Definitions, Needs, Scenarios, Functional Concept, and Modes of Deployment
Chapter 11 – Auxiliary Medical Services in a Field Hospital
Chapter 7 – Personnel
Chapter 17 – Wound Management in a Field Hospital Environment
Chapter 25 – Infectious Diseases and Public Health in a Field Hospital
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