Disaster Response: Care Outside the Box

Disasters can happen anywhere, at any time. As you read through the following examples, consider what you would do in your work setting if faced with similar challenges. What can you do to be better prepared if emergency care becomes necessary?

Insights From a Disaster Response Nurse

In my career, I have been deployed to disasters and public health emergencies around the world that challenged how I provided care. Those challenges included:

• The type of disaster response
• The high acuity of the patients
• Personal safety concerns that prevented me from delivering care
• A lack of or delay in resources due to the remoteness of the environment
• Supply shortages due to emergent need surpassing availability

Often, when a sterile environment isn’t feasible, procedures are performed in the cleanest place possible.

What constitutes a disaster?

Any disruption to your clinical practice setting could be a disaster, but generally there are two kinds: human-caused and natural. Human-caused implies that a person caused the destruction, as in a terrorist attack or bombing. Natural refers to events such as hurricanes, floods or wildfires.

Capacity: What We Need in Order to Respond

Does your work setting have the capacity to care for more than 10 critical care patients? In a hospital, nurses can call in more staff, hold staff over, or find staff support from other floors. However, imagine a mass casualty incident (MCI) with more than 10 critical care, intubated patients in a shelter or field hospital. Depending on the type of disaster, it might not be feasible to call in more staff, have someone go to another unit to get more equipment, or transfer patients to a higher level of care. Family members are often relied upon to provide patient care and support. They are educated to look for signs that indicate their loved one’s condition is deteriorating, and then report to the nurse. Since electricity is not always available, family members may also be taught how to ventilate an intubated patient. In such settings, nurses feel immense mental pressure as they look at one patient while simultaneously providing care to another, and hoping something else doesn’t happen that requires their intervention.

If a disaster occurs, how would you face capacity issues in your facility?

Location, Location, Location

Location is important to consider for egress in case an evacuation is needed. Know where your exits are and your facility’s evacuation policies and procedures. During a disaster, your facility may open tents or create impromptu outdoor care areas. Once a field hospital is set up, it is rare to move it, since finding another safe, central location is often challenging, and the hospital must get word to the people who need medical attention or to those who are bringing in patients. Communication during any disaster is usually difficult, so nurses must consider the centrality of the location so that ambulances and other transport vehicles can get to the site promptly.

Care locations can also affect the availability of supplies. In an unusual care environment such as a tent, you can’t push a call bell to have a co-worker run out for a missing item. During disasters, we must improvise and make do with the equipment within our reach, even if it may mean suboptimal care for the patient.

Strategically placing supplies is key to being ready to provide supportive care during a disaster. Knowing the evacuation plan is vital for our own safety and that of our patients. I am reminded of the stories of heroic nurses who evacuated patients during wildfires. Those nurses and prehospital staff deserve a shoutout!

When was the last time you evacuated your unit? Who determined which patients were evacuated first? Where did any additional staff come from, and how long did they take to arrive? What additional supplies or equipment were needed? During a disaster, time is of the essence. How fast could your team safely evacuate patients to another hospital or remote location, if needed, and logistically, where would the transport vehicles come from?

If you aren’t aware, determine where your disaster response plans are kept, and review them to learn your facility’s plans in case of a disaster.

Interoperability

Interoperability, the ability of diverse groups, departments or teams to work together toward a common goal, is vital during a disaster. A mitigation strategy improves preparedness by enhancing our ability to work with internal and external stakeholders. With this strategy, forward-thinking planning has already taken place so that other departments in the hospital, such as radiology, can provide patient care with minimal disruption. Similar to a hazard vulnerability assessment (HVA), a mitigation strategy should identify and analyze the risk. While it may be impossible to prepare for every disaster, being proactive enables us to consider lessons learned and start implementing changes, as needed. Building relationships with community organizations is important to build trust and promote resilience before disaster strikes and in its aftermath.

Internally Displaced People and Refugees: Unique Care Needs

An internally displaced person (IDP) is someone who has been forced to flee their home due to conflict or other disasters. IDPs do not cross international borders, but refugees do. Imagine having to provide care to IDPs or refugees who have fled their homes: They may not have access to healthcare due to challenges in their region, and these barriers can lead to worsening injuries and comorbidities. Further, these patients may fear seeking medical care and face tremendous trauma that impacts their mental health.

Environmental events such as hurricanes, floods and earthquakes can cause IDPs or refugees to present for care with compounding illnesses as a result of a natural disaster. We can advocate for culturally appropriate care, provide resources in the patient’s native language and, most importantly, be aware of our biases and how they can impact care.

Pediatrics

In a hospital setting, we can reach out to providers when we need support for a pediatric patient, but during a disaster, it isn’t as easy as calling the pediatric floor. While designated pediatric providers are sometimes available, at other times, we must complete just-in-time training to get a crash course on caring for pediatric patients impacted by a disaster.

Pediatric patients may have injuries that aren’t visible. Children may have been separated from their parents, other family members or caregivers, which can impact their mental health. They may be trying to understand what is happening. A child’s response may range from extreme stoicism to loud yelling and acting out. Nurses must also consider a patient’s culture, what they have seen and how they have lived. Providing children with toys, television or the ability to walk around freely may be luxuries that were never afforded to them and may impact their coping mechanisms.

Nurses can prepare to care for patients from a wide range of ages and backgrounds by proactively brushing up on their skills and taking classes that expose them to populations they are not used to caring for. Also, determine whether your facility has the necessary equipment to care for pediatric patients during a disaster.

Hazmat Events

The ongoing conflicts in Gaza and Ukraine have highlighted the disastrous complications when chemicals affect civilians, healthcare providers and hospitals. Chemical and hazardous material (hazmat) events are not unique to war zones; large-scale chemical incidents have the potential to affect dozens to thousands of people in our communities. Not only do we need to be aware of the impact of chemicals on patients, but also the impact of those chemicals on our soil, drinking water and environment. Are there potentially long-term health effects?

More questions to ask yourself:

• Can we care for multiple patients at the same time who have been contaminated with a chemical substance?
• What about possible complications due to a delay in care?
• Do we have the capacity to adequately care for these patients?
• What if it wasn’t an isolated incident and dozens were affected?

Nurses must be proactive in response to hazmat situations. Know your facility’s hazmat protocols and what your role will be if presented with an MCI with multiple chemical or hazardous material contaminations.

Crisis Standards of Care

Crisis standards of care are meant to provide guidance during a disaster on how to shift focus from delivering the best care to individuals to the best care for the most people in an area. For example, during the COVID-19 pandemic, pediatric ICUs shifted to care for adult patients. Patients with extensive comorbidities were not prioritized due to the scarcity of equipment and resources and the likelihood they would make it through. Although crisis standards of care help guide us in this process, the delivery of care depends on the hospital infrastructure and the staff. The variability of standards and their usage often highlight preexisting inequities in healthcare.

To support disaster response preparation, many organizations have a binder of disaster resources, plans and protocols. Have you reviewed this binder recently? When was it updated? Are the contacts current? Is there a section on implementing crisis standards of care? Do you know what your role will be during a disaster?

Disasters and Your Mental Health

The COVID-19 pandemic highlighted the many challenges nurses face daily and how they impact our mental wellness. Occupational risk factors for mental illness are underlined by the alarmingly high rate of suicide among nurses. It is essential that we take care of ourselves and consider who is taking care of us so that we can continue to care for others.

Healthy coping mechanisms and outlets for stress are necessary for a career that supports nurse wellness. Do you have a safe and healthy outlet to manage feelings of frustration, anger or exhaustion? While the culture is slowly changing, there is often stigma related to seeking mental health support. Sharing our own experiences can help reduce that stigma. I use digital mental health support services, which give me different ways of communicating with my therapist depending on how I am feeling. Each disaster response can trigger a reaction in me that impacts my feelings. As nurses, we should be leaders in advocating for our own mental health and that of our patients and their families.

Care Outside the Box

My intent here is to empower you to think outside the box, get prepared and determine ways to mitigate the care challenges that arise during a disaster. Be proactive. Whether natural or human-caused, disasters require us to face unfamiliar challenges that affect our delivery of care and mental health. We must start thinking about how to react if any of these events occur.

Last, in the words of AACN President Terry Davis, “Rising together, we will lift each other up. Rising together, we will advance our journey. Rising together, we will manifest the future.” Be prepared to rise together in the face of the next disaster.

How are you preparing to provide critical care during a disaster?

Editor’s note: This story includes discussion of suicide. If you or someone you know needs help, the national suicide and crisis lifeline in the U.S. is available by calling or texting 988. There is also an online chat at 988lifeline.org.