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September 9, 2005

Disaster Response Part I

Dr Chris Colenda, dean of the Texas A&M College of Medicine, gave volunteers from the medical school a presentation on post-traumatic stress, acute stress, and what to expect from evacuees in the coming months. A quick outline: the nature of the problem, survivor response, and a separate note on lessons from the military.

Problems are simple (need gas - get gas), complicated (need gas and there's a hole in the gas tank), or complex (need gas, the car just exploded, three people are injured, no help is on the way, vultures are circling). A key function of leadership is to reduce complex problems, like the aftermath of Katerina, to a set of complicated problems. [Ed. Leaders should also remember C4I: Command, Control, Communications, Computers, and Intelligence. More on that in a separate post, Disaster Response Part II, currently in draft].

Survivors typically go through a sequence of recovery, starting with heroic measures for a few days, followed by a honeymoon period where the transition is aided by others. The honeymoon typically starts a few days out and last a month or two. Then a sense of disillusionment creeps over life as progress does not seem to be happening, goals seem hard to achieve. This comes on during the honeymoon and may last six months. Finally there is a phase of returning to normalcy, where the words and actions of people start to match again.

The survivors also have a predictable set of four problems: emotional (anger, numbing, despair, overwhelming appreciation for aid, terror, irritability, worry, anxiety, dissociation, lowered self-esteem, sadness, startle response, hallucinations, psychotic symptoms), cognitive (difficulty concentrating, judgement impaired, the frontal lobes sort of disengage, memory, confusion, vocational impairment, spacey, school impairment), physical (fatigue, hyperabnormal, disturbed sleep, headaces, gastrointestinal, respiratory, libido, immune suppression, disordered eating), and interpersonal (alienation, social withdrawal, conflicts, isolation, dependency).

The general approach to crisis counseling is prospective. Home and community based, it should focus on assessment of strengths, adaptation of existing coping skills, and developing new ones. The goal is to restore the survivors to pre-disaster function. For this there is some need to accept content at face value. [ed: this is similar to my training as a Navy casualty assistance calls officer: tell the next of kin that the soldier "is dead", rather than "has passed on" or "is in a better place". The use of factually correct words is vital to giving the next of kin the correct starting point for the grieving process]. Counselors should seek to validate the appropriateness of reactions (see the four problem sets above), and emphasize that these are normal reactions to abnormal events. Finally, at this point it should be obvious that the counselors should maintain a psycho-educational focus.

Let me end this with some additional information from Brigadier General John Allen, USMC, provided to those of us on his staff while he was the Commandant of Midshipmen at the Naval Academy. In the recovery process, you cannot overvalue the importance of group cohesion. It is the nature of disaster, crisis, and war to deliver fragmentary information to each individual; the event involved a group of people. It is the group that needs to grieve and adjust. Those involved need to speak with other survivors who alone have the information that will allow each individual to cobble together the events that unfolded. This was a major lesson out of Vietnam for psychologists that studied Army and Marine veterans. The Army rotated soldiers in and out of units as individuals. Individual soldiers would be in LA Monday, and meet their new unit in the jungle on Tuesday. The Marines went over on ships, as units, they spent three weeks traveling there, and the survivors spent three weeks traveling home together, still in their units. The marines had a dramatically lower incidence of virtually every stress disorder.

Individuals understand this instinctively, whether the group is a nuclear family or an infantry division. I most recently saw this at St Anthony's special needs shelter in College Station, as we weathered Rita with nursing home patients from Galveston. We offered those with more serious needs the opportunity to go to a more capable facility before the winds picked because we were concerned power would go out(we were in a grade school gymnasium, often with only one retired RN and some first year medical students). To a patient they declined. Dialysis, oxygen, surgical wounds, decubitus ulcers, didn't matter: they chose to stay with their group.

Posted by Niels Olson at September 9, 2005 11:32 AM

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