mental health consequences of bioterrorism - year 2: an advanced course for hospital emergency...
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Mental Health Consequences of Bioterrorism - Year 2:
An Advanced Course for Hospital Emergency Department
Clinical Staff
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Supported by Grant Number U3RHS04301-01-00 from the Health Resources and Services
Administration (HRSA). Its contents are solely the responsibility of the authors and do not
necessarily represent the official views of HRSA.
Disclaimer
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Acknowledgments
Written by Rebecca Smith, MD
Curriculum Development & Review Committee:Grant Brenner, MDKristina Jones, MD
G Luke Larkin, MD, MS, MSPH, FACEPCraig L Katz, MD
Roger Nathaniel, MDCarol North, MD, MPEIlisse Perlmutter, MD
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Why another course in psychosocial aspects of
bioterrorism?
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OverviewDidactic - 20min Using the SARS epidemic, we’ll illustrate:
• Key psychosocial dimensions of a bioterrorist attack relevant to ED staff
• ED staff are at increased risk for being both victim and vector
• Communication between individuals, institutions and groups about risk appraisal
Cases – 50min• Applications to ED staff• Psychosocial preparedness & mental health issues • Development of risk communication – based
strategies for individuals and groups• Differentiation of acute presentations of severe
distress from diagnosis, Integration of psych first aid into routine care.
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Emergency vs. Disaster
• As ED staff, you all handle the extraordinary, QD!• You always have capacity to handle the
extraordinary, right? But...• In disasters, needs exceed capacity, for ALL
systems, even the ED – Normal procedures insufficient.
• What will it be like for YOU to be in a situation where needs exceed capacity?
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Core Competencies
1. Identify psychosocial vulnerabilities of ED Health Care Workers as first responders in BT attack & develop a plan for preparedness
2. Understand principles of risk communication & apply to communication with individuals & crowds
3. Differentiate distress v. diagnosis– Common post-disaster mental health myths– PTSD symptoms ≠ PTSD!
4. Integrate Psychological First Aid into care
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Psychosocial Vulnerabilities of ED Health Care Workers
• ED Health Care Workers are First Responders for the nation, 24/7
• ED already a combat zone of austerity & overcrowding
• Increased Risk for Infection in EDVictim/Vector
• Big changes in work and home role
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SARS timeline
ABCDEFGHIJKLM
Onset of symptoms Time stayed at Hotel M
February March4 531 624 25 26 227 2820 21 22 2315 16 17 18 19
Hotel MetropoleHong Kong
From Brendan Flannery, PhD, the CDC SARS Investigative Team
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Hotel MHong Kong
Guangdong Province,
China A
A
H,J
A
H,J
Hong Kong SAR
95 HCW
>100 close contacts
United States
1 HCW
I, L,M
I,L,M
KIreland
0 HCWK
Singapore
34 HCW
37 close contacts
C,D,E
C,D,E
B
B
Vietnam
37 HCW
21 close contacts
F,G
Canada
18 HCWF,G
11 close contacts
SARS transmission:Health Care Workers & Families
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Example: SARS8437 Probable Cases
China: 5327(Beijing: 2521)
(Guangdong: 1511)
H.K.: 1755
Viet Nam: 63
Singapore: 206
Canada: 250(Toronto: 242)
Taiwan: 671
As of July 11, 2003. Source: WHO
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Isolation & Quarantine
• Both are methods of “community containment.”• Isolation: the separation of persons who have a
specific infectious illness from those who are healthy, and the restriction of their movement to stop the spread of disease.
• Quarantine: the separation and restriction of movement of persons who, while not yet ill, have been exposed to an infectious agent and therefore may become infectious.
• Both can be either voluntarily or compelled by public health authorities.
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Toronto Outbreak, Spring 2003Paramedics on Quarantine
0
20
40
60
80
100
120
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39
Day of Outbreak
# o
f p
ara
me
dic
s
Total Staffperson-Days on Quarantine = 2035
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2003 SARS Outbreak Acute Psychological Responses
• Patient reactions:– Isolation, loneliness, stigma– Anxiety associated with fever spikes– Fear and guilt about well-being of family/friends
– Insomnia
• Staff reactions:– Conflict between work & family responsibilities– Complexity of caring for other HCWs
– Diminished control, freedom, self-esteem
(Maunder et al, 2003)
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Personal Preparedness Planning• You have a disaster plan at work. The hospital has one.
– Do you know it?• But do you have a disaster plan for yourself and your family?• What sorts of BT training & support are available for you in
your hospital or on the web?• Bioterrorism Literacy:
– What is ICS? – State and Hospital plans and policies re: Quarantine &
Isolation?• Psychosocial Literacy:
– What are your sources of resilience?– How do you actively cope?
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Principles of Risk Communication: Treatment and Prophylaxis
for Anxiety and Panic1. Listen to, acknowledge, and respect the fears, anxieties and uncertainties:
- they want to know that you care before they care what you know.
2. Appear calm and in control, even in the face of public fear, anxiety and uncertainty; provide others with ways to participate, be constructive, channel their energy, and regain control.
3. Offer authentic statements of caring, empathy, compassion and listening; back up those statements with actions.
4. Be honest, ethical, frank, and open, recognizing that there are limits on what needs to be disclosed.
5. Avoid using humor; if humor is needed, plan and test carefully.
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Principles of Risk Communication
6. Be hopeful so as to avoid fixation on the negative.- avoid the five N’s: no, not, never, nothing, none
7. When providing info or sharing bad news, be proactive but remember – Need 3 positives to balance 1 negative.
8. Avoid mixed or inconsistent verbal and non-verbal messages
9. Hone verbal & non-verbal media skills. - Avoid major media traps, guarantees, speculating on worst case
scenarios. Covello, 2004
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Assessing Patients Psychological Assessment Principles
• What is known about the event, including its known scope, impact, and public health implications?
• Who is the person in front of me, including their personal, social, and psychological history as well as their connection to the disaster?
• When in the time course of the event is their ED visit occurring?
Katz, 2004
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Acute Psychological Responses (intense but changeable)
• “Stunned”• “Shocked”• Anger at authority• Feeling abandoned• Uncommon vulnerability• Exaggerated rumors• Intense love / altruism• Heroism / Industry• Desperation
• Bewilderment• Fear• Impasse• Numbness• Apathy• Helplessness• Urgency• Discomfort• Confusion
(Wolfenstein, 1957)(Katz et al, 2002, 2004)
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Bioterrorism and Mental Illness
• Acute Stress Disorder (can only diagnose within 30 days of trauma)
• Post Traumatic Stress Disorder (can only diagnose AFTER 30 days post-trauma)
• Major Depressive Episode/Disorder
• Panic Attack/Panic Disorder
• Generalized Anxiety Disorder
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Assessing PatientsPsychological First Aid
• provide for basic needs (water, blankets, privacy)
• protect from further exposure – reduce environmental stimulation or agitation
• support the most distressed• keep families together & provide social support
– awareness of impact on entire family• provide information, foster communication and
education– orient to available services– use effective risk communication techniques
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Web Resources
• www.cdc.gov “emergency preparedness” • www.bt.cdc.gov “cdc bioterrorism info”• www.nyc.gov/health/nycmed 1-888-NYCMED9• Health Alert Network, gives you emails on alerts”
from the NYS dept of health and mental hygiene Email: [email protected]
• CDC health alerts, learning modules • www.phppo.cdc.gov/han/