Caregivers and rescue workers—including psychi-atrists—are also disaster survivors, and you need to tend to your needs for safety and support. Consult frequently with colleagues within and outside the disaster area, as much for support as for information and guidance.15 Remember also that rescue workers are occasionally targets for victims’ rage at their circumstances. Anticipating and explaining this displacement reduces its toxicity.
Using medications
Uses psychotropics judiciously in the first 48 hours of trauma. Medication effects may interfere with neurologic assessment of the injured, and monitoring and follow-up may not be possible.
However, drug therapy should start quickly when survivors are acutely psychotic or their behavior endangers themselves, others, or the milieu. Medications usually include a fast-acting benzodiazepine and/or an antipsychotic, as described in guidelines for managing agitation.16 Always provide structure and supervision for medicated patients.
No guidelines exist for using medications to manage distressing—but less-severe—acute stress-related symptoms. Some experts advocate using adrenergic antagonists such as clonidine, guanfacine, and beta blockers to reduce excessive arousal. These drugs have not been adequately studied in this setting, however, and may harm those with cardiovascular instability from preexisting conditions or injuries.
Table 3
Psychoeducation: Simple messages for workers and trauma survivors
| Get adequate rest, food, sleep |
| Avoid exposure to trauma cues, including TV images |
| Seek support from loved ones and peers |
| Talk about events and feelings only if this feels comfortable and helpful |
| Return to normal routine as much as possible |
| Take action to rebuild, but at a reasonable pace |
| Reach out to others who may need assistance |
Get help:
|
Short-term (<1 week) benzodiazepine use for panic symptoms and severe insomnia is acceptable, but longer-term use may increase PTSD risk.17 A selective serotonin reuptake inhibitor may help individuals with pre-existing PTSD or depression, if you can arrange follow-up.
In the aftermath
‘Debriefing.’ Critical incident stress debriefing (CISD) is a structured, one-session group intervention in which survivors’ experiences and emotional reactions are discussed and education and follow-up recommendations are provided. Developed by Mitchell in 1983,18 CISD was widely used until systematic evaluations revealed that it did not alleviate psychological distress or prevent PTSD.19
Table 4
How to interact with news media during and after a disaster
| For organizations Identify a spokesperson with media experience beforehand Ensure that the spokesperson is well-informed about all aspects of the disaster |
| For spokespersons |
Always
|
Never
|
Thus, although survivor meetings may provide information, education, screening, and support, avoid detailed discussions of events and emotions. Any meetings should be conducted by mental health clinicians and should not be mandatory. Reserve the term “debriefing” for operational reviews by rescue personnel.20
Public education. Educate survivors, rescue workers, health care providers, teachers, and relief agency workers. Provide concise, simple messages as suggested in Table 3. News media provide our most effective means of reaching out to survivors, which is why having a pre-existing relationship is so important. Some guidelines for working with the media are presented in Table 4.
Outreach. Numerous educational resources are available for survivors and their caregivers (see Related resources). Other potentially useful outreach tools include:
- meetings with teachers’ organizations
- continuing medical education activities for primary care providers
- telephone hot lines.
Legal and ethical issues
Disaster scenes are chaotic and informal, and professionals must be flexible, often providing general support and information rather than specific clinical interventions. However, it is important in each encounter to decide whether a patient-physician relationship has begun.
As a general rule, a physician-patient relationship is established whenever diagnosis or treatment is discussed. Once that happens, briefly document:
- signs and symptoms
- working diagnosis
- suicide or violence potential
- treatment and/or follow-up plans.
Confidentiality may be difficult to preserve in chaotic situations involving workers from many agencies. Even in disasters, however, you must obtain permission before sharing information unless the individual’s situation is emergent.
Table 5