Trauma in Disaster

Trauma inDisaster

David AlexanderUniversity College London

Evidence

"Now, what I want is, facts. Teach these boys and girls nothing but Facts.Facts alone are wanted in life. Plantnothing else, and root out everythingelse. You can only form the minds ofreasoning animals upon Facts: nothingelse will ever be of any service to them. This is the principle on which Ibring up my own children, and this is theprinciple on which I bring up thesechildren. Stick to Facts, sir!"Thomas Gradgrind in Hard Times

by Charles Dickens

An evidencebase for

everything

Robert Mallet andevidence-based seismology

Evidence can be:-• precise• decisive• equivocal• ambiguous• puzzling• uninterpretable

(evidence of what?)• ignored• distorted• used selectively.

Evidence is no good withoutinterpretation - and the ability tointerpret without misleading people.

Evidence can constrain uncertainty,but cannot eradicate it.

All use of evidence is selective:the criteria of choice determine

the value of the evidence.

Irregular and trending time series poseproblems for the gathering of evidence.

To what extent is evidence asurrogate for experience?

Is evidence "objective data" ormere perception of how the world is?

What is the connectionbetween evidence and wisdom?

How much evidence is enough?Can we do without evidence?.

Analysis

• registered• archived• forgotten• ignored

Vulnerabilitymaintained-

• utilised• adopted• learned

Disasterriskreduced

+

LessonsPast

events

The process ofdisaster riskreduction(DRR)

Disaster injuryepidemiology

DISASTERVICTIM

NOT INJURED INJURED

HEALTHY INFECTEDWORSENING

OF PATIENT'SCONDITION

IMPROVEMENTOF PATIENT'SCONDITION

RECOVERS

IMPROVEMENTOF PATIENT'SCONDITION

DISEASES INJURIES

Public health measures

Search and rescue

Mortuaryand funeralservices

WORSENINGOF PATIENT'SCONDITION

DEATH

Medical assistance

Medical assistance

Physical injury (physical trauma):-• short-term condition• long-term injury or disease• fatal injury• premature death

Psychological impairment:-• depression• anxiety• post-traumatic stress

(including long-term).

Disaster injury epidemiology

Earthquakes

Mortality in earthquakes• concentrated in the largest events• concentrated in particular places

Instantaneous:• crush injuries• cranial or thorax injuries• internal haemorrhaging

Rapid (from minutes to hours):• asphyxia• hypovolemic shock• exposure

Earthquake injuries

Delayed (hours to days):• dehydration, hypo- or hyperthermia• crush syndrome• infection or post-operative sepsis.

0.5 1 3 12 1 2 3 45 7 10 15Hours Days

Survival time

100

50

0

Perc

ent

age

of

peop

le t

rapp

ed a

live

under

the r

ubble o

f co

llaps

ed b

uildings

Critica

l pe

riod

Source: Coburn and Spence (2002)

No damageto buildings

Damageto buildings

InjuriesEmergency roominjuries

Hospitaladmissions

Source: Linda Bourque, UCLA

In the largest earthquakes

• mortality is 10-85% ofpopulation of the epicentral area

• death/injury ratio 1:3 (hypothesized)

• casualties lessen rapidly withdistance from the epicentre.

Factors that affect mortality andmorbidity in earthquakes

• type, density and state ofmaintenance of buildings

• number of occupants of buildings

• post-earthquake fire

• time of day (aggregatepatterns of human activity).

Active behaviour:• travel to and from work• leisure activities, etc.• mealtimes and family activities

Passive behaviour:• night-time sleep• efficiency and timeliness of post-

earthquake SAR and medical assistance.

At the world scale, most injuriesoccur in nocturnal earthquakes:• a sleeping person is notable to react rapidly

• vernacular housing is particularly at risk• 50-90% of mortality is nocturnal.

Pattern of injured people

• most numerous group: minor injuries

• smaller group: simple fractures

• smaller group: serious multiple injuries

• ratio of serious to slight injuries:from 1:9 to 1:30.

Expected pattern of injuries

minor injuries:bruises, lacerations, etc.

simple fractures

seriousmultiple injuries

Ratio of serious to slight injuries:from 1:9 to 1:30

dead

Fatal injuries

Allinjuries

Seriousinjuries

low ratio

low ratio

high ratio

Types of injury

• crush syndrome

• clavicle fracture

• simple lacerations

• bruises and sprains

• fractures of limbs

• surgical cases.

Types of injury (contd.)

• orthopaedic cases

• acute myocardial infarction(heart attack)

• neurosurgery cases

• shock

• severe burns or smoke inhalation

• paraplegia.

Types of injury (contd.)

• gangrene, amputation

• adult respiratory distresssyndrome (ARDS)

• psycho-physical andpsychosomatic problems

• animal bites, electrocutions, drownings

• aggravation of existingmedical conditions.

Ratio of deaths to buildingscollapsed- 8:100 to 16:100

Entrapment increases riskof death 35-100 times

• respiratory difficulties caused bypressure on thorax of fallen objects, orby ingestion of large quantities of dust

• 2-6 hours after earthquake fewer thanhalf of trapped people will still be alive.

Medical procedures

• patient's condition must be stabilisedimmediately after he or she is rescued

• advanced trauma life support (ATLS)

• life support first aid (LSFA)

• resuscitatory surgery

• field analgesia and anesthesia

• resuscitative search and rescue

• intensive therapies.

Disaster Risk Reduction

or disaster risk creation?

L'Aquila earthquakeApril 2009 (308 dead)

Kobe 1995 earthquake deathsby gender and age

― males ― females

Self-protectivebehaviour

Hospitalmass-casualty

response

Urban searchand rescue(USAR)

A practical disaster epidemiology

Focus Potential benefit to...

How, whereand why

people died;who they were;

how theyreacted tothe disaster

Behaviour

Vulnerability of thebuilt environment

Interaction

Force majeure:the earthquake

Perception

Knowledge, habit,custom and training

?

Vernacularhousing:the mainsourceof risk

This is where we need resilience...

Can we devisea strategy to enhance

self-protective behaviour?

Poor buildingquality

(low seismicresistance)

Proximityto epicentreand faultrupture

Topographicamplification

Sedimentaryamplification

Q E

T S

Concentrationof casualties

C

C = f { E,Q,S,T }

Deaths

Injuries

Q E

T S

Building quality and seismic resistance:

• site factors


• building type and materials

[Masonry] [Reinforced concrete]

• plan and elevation of building



• urban form factors

[poundingbyadjacentbuildings]


• mixed construction?

[Stone andconcreteblock]


• state of maintenance


• occupancy factors

One needs to investigate the relativeimportance of these factors in

different situations

sitefactors

building typeand materials

plan andelevationof building

urban formfactors

mixedconstruction?

behaviouralfactors

Mid-floor damage to multi-occupancy bldg:

Intertia effect

Basal acceleration

Interaction = damage

Lack of stiffness in frame

For example... what is the typicalpattern of seismic failure of Iranianvernacular housing of any given type?

• basal acceleration• inertial displacement• spalling of façade• torsion• ejection ofinfill masonry

• deformation ofstructural nodes

• detachment ofinternal stairways

Some possible modes of failure

Think of theproblem fromthe point ofview of theoccupantsof a building:occupant-buildinginteractionmodes.

Boumerdes, Algeria 2003

A scale for damage and personal risk level

Damage level: [1] minimum damageto walls, fitments and furniture.Personal risk level: prudentbehaviour will minimise risks.

Damage level: [2] significant damageto structures, cladding and fitments.Personal risk level: significantrisk of injury but not of death.


Damage level: [3] general damage andcollapse of architectural elements.Personal risk level: significant risk ofinjury but relatively low risk of death.


Damage level: [4] serious damageor partial collapse of building.Personal risk level: strong risk ofinjury and significant risk of death.


Damage level: [5] collapse ofmore than 50% of the structure.Personal risk level: limited and mainlyunpredictable probability of survival.


In the case of total collapse, littlecan be done for the occupants of abuilding except urban heavy rescue.

This is up to three times more likelyto be successful if the locationof trapped occupants is known

(e.g. they can attract attention).

Seekplace ofrefuge

Remainin situ

SeekpotentialcavityRush

outside

Unexpected earthquake

Mildimpact

Severeimpact

Catastrophicimpact

Verylimiteddamage

Fall ofheavyobjects

Partialcollapse

Totalcollapse

Absolute immobility Frantic egress

UninjuredLightlyinjured

Seriouslyinjured

Killed

Earthquake scenario• magnitude range• maximum accelerations• recurrence intervals, etc.

Seismicperformanceof buildings• modes of failure• typologies of damage

Risk factors• behaviour of building occupantsduring earthquakes

• effectiveness ofsearch and rescue

Models of typical vernacular housing

building types

Analysis ofcharacteristicfailure modes

Determinationof appropriatecrisis behaviour

Education andtraining ofhouseholds

Culture ofprotection

and resilience

Psychological trauma

It is very rare that acutepathological reactions and lasting

mental illness are caused by disaster.

Instead, the most commonconsequences are:-

• depression

• post-traumatic stress disorder(PTSD), including criticalincident stress (CIS).

Disaster is a test of thepsychological stability of the individual

• healthy behaviour meansactivating internal mechanismsthat restore a sense of calm

• unhealth behaviour means thenegation of experience ordisintegration of the personality.

How an individual receives signs of danger:

• decoding them and reacting appropriately

• negating them and not reacting

• not understanding their significance andnot reacting in the most appropriate way:- e.g., when the environmental signs of

disaster are neither clear nor familiar

• understanding them, but neverthelesslosing his or her equilibrium:- the persion is overwhelmed

by fear of death and feelsabandoned or too vulnerable.

Riskaversion

Risktolerance

Riskdenial

Risk-seekingbehaviour

Critical incident stress (CIS)is a form of

post-traumatic stress disorderwhich affects first responderswho work in conditions that aredifficult, dangerous or dramatic.

• physical (e.g. nausea, upset stomach)

• cerebral (e.g. repeated bad dream)

• behavioural (e.g. angry outbursts)

• emotional (e.g. anxiety)

• immediate or delayed.

Symptoms of PTSD and CIS

In emergencies loss of sense of perspective can occur, leading to:-

Magna Mater complex: trying to solve all the problems of the moment

Jehovah complex: believing one isable to solve all existing problems

Tiredness can distort perceptionand cause bad decision-making

Solution: take a break, rest and unwind.

Panic?

Criticisms of the concept of panic:-

• social chaos may mask rational individual behaviour

• panic is a stereotypeand a popular myth

• running away might be the mostrational response to imminent danger

• hindsight analysis cangive the wrong perspective

• social bonds can survive major shocks.

Nepal

• reference scenario: M7.4 event of 1934

• major earthquake expected circa 2004.

Nepal earthquakes of 25 April(M7.8) and 12 May (M7.3)

1934

• poverty, polarisation andgeneral lack of governance

• almost universal absenceof disaster preparedness.

Nepal

• municipal disaster managementarrangements adequate for a villageof 1,000-2,000 inhabitants, nota metropolitan area of 1.6 million

• airport far too small (cf. Haiti)

• basic preparedness virtually absent

• international community ineffective

• disaster risk reductionmeasures very recent.

Kathmandu

• Why does disaster risk reduction havesuch a low priority in national agendas?

• Why does so much internationaleffort achieve so few results?

• Why does the international communityfocus on sophisticated aimsand ignore basic preparedness?

• What is the point of the SendaiFramework for Disaster Risk Reductionif it fails to reach the local level?

• Why is it so difficult to achievepositive cultural change?.

Basic preparedness is a matter ofcommitting and organising the resources

that already exist: it is not unaffordable.

The barriers to preparedness:• perception and interests of

powerful decision-makers• corruption (the real cause

of earthquake disasters)• polarisation, ideology and dogma• lack of accountability:

"simulated ignorance".

david.alexander@ucl.ac.ukemergency-planning.blogspot.comPresentations can be downloaded from:-

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Thank youfor yourattention!