Introduction

Any disaster – natural or human made – carries an urgent medical need. Most of the declared needs in the immediate aftermath of a mass trauma are physical, with surgical and orthopedic interventions in the immediate phase and medical problems with endemic epidemiological aspects in the next phase. Historically, the medical focus in disaster preparedness has been on injury, infection, and exposure related illness, but clinicians have been interested in postdisaster mental-health interventions since the 1940s[1].

Unlike physical injuries, adverse mental-health outcomes of disasters may not be apparent during the initial phases following the event, and therefore are often overlooked, but these mental outcomes due to exposure to a disaster are common. One-third or more of individuals severely exposed may develop posttraumatic stress disorder (PTSD) or other mental disorders – new or exacerbated. A systematic approach to the delivery of timely and appropriate disaster mental-health services may facilitate their integration into the emergency medical response[1,2] and improve their overall outcome. Among the mental disturbances, other than PTSD, the individuals might suffer from disorders such as adjustment disorder, major depression, and psychotic breakdown, as well as behavioral manifestations such as substance abuse, violence, helplessness, and suicidality.

The general society breakdown, personal and material losses, and physiological hardship (whether due to physical injury or to lack of food or shelter) make all the traumatic experiences severe and the chance of an unharmed long-term remission less probable.

Despite its severity, most victims of mass trauma tend to ignore the mental problem at first and most manifestations are those of the physical problems. As an example, during the post-tsunami medical care in Indonesia, evaluated at the Red Cross Hospital at Banda Aceh[2], the complaints were of the following: (1) urological (19%), (2) digestive (16%), (3) respiratory (12%), and (4) musculoskeletal (12%). Although < 2% of patients were diagnosed with a mental-health problem, 24% had at least four or more of the seven depression/PTSD symptoms addressed in the study[3].

The responders – professional and nonprofessional, working in humanitarian delegations and field hospitals – are also a community at risk for mental disorders. PTSD and depression were the most studied diagnoses with prevalence of PTSD ranging from 0% to 34% and depression from 21% to 53%[4]. The variations in the morbidity rate are due to under reporting as well as the way the responders were screened for the mission[5], escorted during the work, and looked after when it was over[6]. In a large review paper, most samples of rescue and recovery workers showed remarkable resilience. Within adult samples, more severe exposure, female gender, middle age, ethnic minority status, secondary stressors, prior psychiatric problems, and weak or deteriorating psychosocial resources most consistently increased the likelihood of adverse outcomes[7]. Psychiatric outcomes are not the only mental ramification of trauma. Symptoms and unpleasant emotions not qualifying as a psychiatric disorder are referred to as psychological distress. Distress, at some level, is nearly universal after disasters and is far more prevalent than psychiatric disorders. The distinction between these two entities is critical for effective disaster response because different interventions are needed for them[8].

When trying to understand the specific needs from the MHPs in the field hospital, one must understand that, unlike any other crew member, the team must provide assistance to the victims of the disaster-acute phase and long term – in the emergency room as well as in the liaisons work in the departments – but not less important to the team, in the preparedness, actual work, and after the return to safety, in the psychiatric and psychological aspects[7–9].

The integration of psychosocial care into emergency and medical disaster response must occur prior to the disaster itself, and will depend on effective collaboration between medical and mental-health-care providers[8,10].

In this chapter, we will try to conduct an overview of the mental factors crucial for the hospital members, the MHPs needed for the team and hospital work, other missions that should be proposed by those professionals in a humanitarian mission to the area’s population, and the basic screening and treating tools that should be implemented by them.

Field Hospital Team Care

The team must have as much knowledge as possible in regard to the nature of the disaster, the country’s state after the disaster, the mission ahead, its probable length, specific cultural aspects, and specific epidemiological data. The preparedness is different when arriving at safe grounds of a clean area, with no epidemiological threat, like an organized country after a single terrorist attack, and when arriving in a country like Haiti immediately after an earthquake.

At the basis of all procedures taken are the international and national conventions and laws. This implies that the medical assistance is adjunct to the local capabilities and requirements. The treatment should be accessible to all. Treatment should be customized to the traumatic arena while standing on the highest clinical standards of care possible given the limitations[11]. The psychological intervention schemes of treatment are multivariable. The first consideration is the exact nature of the disaster as opposed to the local remaining infrastructure and treating capabilities. The flow of decision is dictated by moral obligation. The psychosocial intervention schemes are multivariable, depending mainly on the exact nature of the disaster and the local remaining infrastructure and treatment capabilities. The decisions will be dictated by moral obligation. They will be discussed according to the different phases of the deployment: pre-deployment, during, and post-deployment.

Prior to the Mission

From the chapter authors’ experience, the three major reasons that people join an altruistic mission are as follows:

1. 
   

   1. Leadership: Leadership in stressful situations should be as structured, concise, and trustworthy as possible. People need to feel that the commander is capable and reliable.

   
   
2. 
   

   2. Camaraderie: The connection between people helps in building up courage. Team members are also willing to make sacrifices to help people they feel connected to. The strength of a group has been spoken of in literature, but its importance cannot be underestimated in a traumatic situation.

   
   
3. 
   

   3. Meaning: The belief that there is something that is more important than themselves at this point of time. This can stem from ethics, religion, spirituality, beliefs, protecting of loved ones, and so on.

Therefore, the initial period while preparing for a mission should be dedicated to strengthening these three principles, and not “just” medical preparedness and equipment readiness.

The team members should meet before departure and engage in different, relevant missions such as preparing the gear for the mission and getting immunizations together. This enables the members to get to know each other on peaceful grounds and start feeling closer to each other before they feel tired and stressed. A team should be built with everyone knowing his or her specific role in the mission, and understanding that everybody has to take part in various combined missions such as erecting the hospital facility. Prior to leaving the country of origin, team members in the mission should be provided with information about the country they are going to and its condition after the trauma, and have people from past missions explaining what to expect. The main tool for this is psychoeducation and team building. This builds resiliency and puts the team at a better starting point for the mission. It is crucial to identify those not participating or those who tend to “cope by themselves.” It is common for the commanding officers of the mission not to take an active part in the team buildup since they have a lot to do at the organization stage. It is important the MHP makes sure the commanders use this time for team building as well. The MHP’s main focus at this point should be getting to know as many members of the team as possible. This includes members from all sectors: medical, paramedical, and logistic support personnel. They must attend as many team talks as possible as side participants, allowing the leadership team to lead the discussion, while taking part themselves. During these talks the MHP must ensure the participants understand that the MHP’s main role in the mission is to help them.

The ideal professional team should include a psychiatrist equipped with medicine and either a social worker or a psychologist. Both should be familiar with different methods for the treatment of acute stress disorder, as well as having the ability for group sessions and leading a debriefing group.

The drugs recommended for a mission like this should include benzodiazepine (BZ), sleeping pills, and major tranquilizing drugs such as olanzapine (tablets and injections). The role of BZ should be minimal as it is known to help in the acute phases, but enhances the incidence of PTSD later on. Selective serotonin reuptake inhibitor medications do not help in early phases; thus, their role is minimal. The specific amounts of medications should be decided prior to the mission according to the nature and location of the disaster and the anticipated length of stay.

The Early Phases of the Mission

This is a crucial phase for the success of the mission, as well as the psychological outcomes of the whole delegation. This can be divided into two major fields of action: (1) a country with poor infrastructure in a large disaster, with a mission adjacent to the disaster, for example Haiti, and (2) a country with a well-established infrastructure in a large disaster, with a mission adjacent to the disaster, for example Japan.

Related posts:

Chapter 6 – Training and Accreditation Chapter 3 – Definitions, Needs, Scenarios, Functional Concept, and Modes of Deployment Chapter 11 – Auxiliary Medical Services in a Field Hospital Chapter 7 – Personnel Chapter 17 – Wound Management in a Field Hospital Environment Chapter 25 – Infectious Diseases and Public Health in a Field Hospital