Department of Obstetrics and Gynecology, Massachusetts General Hospital, MGH Global Disaster Response, Harvard Medical School, Boston, MA 02114, USAUnited States
Department of Medicine, Massachusetts General Hospital, MGH Global Disaster Response, Harvard Medical School, Boston, MA 02114, USAUnited States
Also available as PDF (figures and tables appear in the PDF).
Healthcare professionals who work in the disaster field confront many challenges to the care of victims of natural disasters. Disaster responders face destroyed physical infrastructures, scarce supplies, and a limited trained peer group. During a mass casualty event, healthcare responders will encounter disaster victims who are triaged to the “expectant” category of care because either their injuries are not survivable or the resources needed to care for them surpass what is available. Responders have not been traditionally trained to administer palliative care in a disaster setting. This commentary examines the challenges that responders face in caring for dying patients in the field and advocates for basic palliative care training prior to deploying to a disaster.
Keywords: Disaster response; Palliative care training; Triage; Expectant; management; Expectant management
her arms and legs, and extensive crush injuries leading to acute
renal failure. Her arms and legs were covered in maggots. She was A natural disaster such as an earthquake, flood, or hurricane can
brought to the United States Field hospital in Port Au Prince. She cause significant loss of life, destruction of property, and displace-
was awake, confused, and delirious. Any movement caused exment of surviving populations. The mandate of medical teams
treme distress. She was alone. The rescuers could not find any of who enter a disaster zone is to administer immediate medical
her family members or friends. After a medical assessment, the care to the survivors.1 In a mass casualty event, medical teams are
team felt that she would not survive her devastating injuries and trained to evaluate injured survivors based on the severity of their
she was triaged to the expectant category of care.
injuries, the acuity of their needs, and whether they will be able
to survive from their injuries. Well-established triage systems cat-
The nursing team placed her in a plastic body bag that egorize injuries based on an urgent need for care and survivability.
was zipped up to her chest to contain the extensive maggot bur- For instance, a common system includes the following categories:
den on her extremities. An intravenous line was placed in her sub- “immediate” where the victim requires immediate life-saving treat-
clavian vein and morphine was administered every 30 minutes as ment; “urgent” where the individual requires medical intervention
cc Copyright 2018 by Goodman A. This is an open-access article distributed under Creative Commons Attribution 4.0 International License (CC BY 4.0), which
13,14 within six hours; “delay” where the survivor has minor injuries being able to provide care to “expectant” patients.
or non-life threatening injuries and their care can be delayed; and
“expectant” where the individual will not survive their injuries or While there is little literature on disaster responders and
where the extent of interventions required would overwhelm the palliative care training, a survey of surgeons identified several key
medical system and take away resources for the treatment of other challenges to discussing end-of-life issues with patients and family
people with more survivable injuries.2 members. The majority reported no formal training in palliative
care (76.1%) plus unrealistic expectations among families along
Beyond the identification of patients to the “expectant” with cultural barriers to communication.15
category, medical responders receive little training about how to
care for immanently dying patients during a disaster. This com-
mentary reviews the challenges to care for this category of patient,
the stresses on the medical providers, and some basic palliative
interventions to provide comfort to the patient and their family The case study at the beginning of this commentary describes the
members during this catastrophic time.
creative caring of an elderly woman who was mortally wounded in
the Haitian earthquake. It was not possible to treat her crush inju-
ries or renal failure and the medical team chose to focus on pain
management and being present during this woman’s final hours.
The morphine alleviated her pain and anxiety. However, it was dif-
In a natural disaster or man-made conflict zone, there may be limficult to communicate with the patient because of her delirium and
ited medications to treat pain, and to manage anxiety and distress. other family members could not be found. Her condition was very
Local resources can be disrupted and supplies brought in by outdistressing to watch. In retrospect, a team briefing and debriefing
side responders may be inadequate and delayed. For instance, durwould have supported the nurses who primarily cared for her. In
ing Hurricane Sandy, there was a disruption of methadone mainteaddition, chaplaincy support at the end of this woman’s life and for
nance programs for existing opioid users and concern that opiate the healthcare team could have discussed the meaning of M.C.’s
pain management for new victims of the hurricane would be untragic and lonely final hours.
available.3 Oxygen availability and airway management capability
may be inadequate for the need. For instance, during the first week Codification of normative and operational guidelines for
after the Haitian earthquake, a field hospital had limited oxygen healthcare responders have contributed to the professionalization
availability and a choice needed to be made as to which of the three of both humanitarian aid and medical interventions after a disas-
critically ill patients in their hospital would receive the remaining ter.1 The World Health Organization (WHO) has an essential med-
oxygen supply.4 In another example of extensive burn injuries after icine list that should be brought by medical teams into the disaster
the mass casualty event of the Pope Air Force base disaster, airway setting.16 Basic pain management of all patients should be a man-
management challenges and lack of sufficient clinical personnel datory component of the medical response. Common symptoms
challenged the ability to care for so many severely injured people.5 in palliative care include anxiety, depression, agitation, breathless-
ness, and gastrointestinal distress. Table 1 lists the medications for
Destruction of buildings and of existing medical infrapalliative care as recommended by the WHO.
structure after a disaster can lead to limited hospital bed availability
and limited structures to protect these patients from the weather
ing “expectant” patients, Ho et al identify crowding in temporary Pain Acetylsalicylic Acid, shelters as a significant problem for survivors after the 2015 Nepali Paracetamol, Ibuprofen, earthquake. After the Fukushima nuclear crisis, a loss of medi- Codeine, cal infrastructure led to a shift in palliative care from inpatient to Fentanyl, Methadone home care.
Morphine Amitriptyline
Anxiety & Depression Diazepam Fluoxetine Amitriptyline The first responders to a disaster are members of the affected Agitation Haloperidol community. One stress for healthcare workers of an impacted Midazolam community is the balance of their own needs and needs for taking Breathlessness Dexamethasone care of their families and taking care of victims of their commu- Nausea & Vomiting Cyclizine nity. First responders face safety and security risks while working Dexamethasone in the field after a disaster that can lead to immediate personal Hyoscine Hydrobromide Metoclopramide physical injury and the late effects of post-traumatic stress disorder Ondansetron (PTSD). For instance, one study reported up to a 23% rate of 11 Diarrhea Loperamide PTSD in responders after the World Trade Center Terror attacks. Constipation Docusate In contrast, another report comments on the power of peer sup- Senna port among responders to prevent mental health effects of disaster * 15 This table is adapted from the essential medicine list WHO, 2017.
Spiritual Management Grief Identify meaning
Cultural Training specific to the location of the disaster The meaning of death in the culture Who are the decision makers in the family
Training for difficult conversations Delivering Bad News Managing a grieving family
Self-Care Training Develop a system for debriefing Develop a buddy system Self care exercises: deep breathing, prayer, meditation, yoga
Medical team members should receive basic training in