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Textbook of Disaster Psychiatry Textbook of Disaster Psychiatry Edited by Robert J. Ursano Carol S. Fullerton Uniformed Services University of the Health Sciences Lars Weisaeth University of Oslo Beverley Raphael University of Western Sydney CAMBRIDGE UNIVERSITY PRESS I Assessment and management of medical-surgical disaster· casualties James R. Rundell Introduction identify how postdisaster patient triage and manage­ ment can incorporate behavioral/psychiatric assess­ Having medical or surgical injuries or conditions ment and treatment, merging behavioral and following a disaster or terrorist attack increases the medical approaches in the differential diagnosis likelihood a psychiatric condition is also present. and early management of common psychiatric syn­ Fear of exposure to toxic agents can drive many dromes among medical-surgical disaster or terrorism times more patients to medical facilities than actual casualties. terrorism-related toxic exposures. Existing post­ disaster and post-terrorism algorithms consider pre­ dominantly medical and surgical triage and patient Phases of individual and community management. There are few specific empirical data responses to terrorism and disasters: about the potential effectiveness of neuropsychiatric integrating psychiatric management triage and treatment integrated into the medical­ into disaster victim medical-surgical surgical triage and management processes (Burkle, triage and treatment 1991). This is unfortunate, since there are lines of evidence to suggest that early identification of Disasters include natural disasters as well as human­ psychiatric casualties can help decrease medical­ made disasters such as terrorist attacks with explo­ surgical treatment burden, decrease inappropriate sives, chemicals, and biological agents. In cases of treatments of patients, and possibly decrease long­ disaster or terrorism, particularly when the scope of term psychological sequelae in some patients potential casualties could overwhelm local response (Rundell, 2000). Physicians and mental health pro­ capabilities, the ability to separate medical-surgical fessionals involved in disaster/terrorism response casualties, psychiatric casualties, mixed casualties, planning should understand the importance of con­ and the worried well becomes crucial to targeting aid sidering behavioral symptoms within the context of to the correct patients. The principles of differential concurrent medical-surgical assessment and treat­ diagnosis discussed in this chapter are aimed to be ment (Rundell, 2003). Effective medical-psychiatric clinically useful across the range ofdisaster etiologies. differential diagnosis and adequate attention to Following a potential terrorism or disaster-related .1 ;1 public risk communication lessen the risk of medical toxic (biological, chemical or nuclear) exposure, or a ""I or psychiatric misdiagnoses, and decrease the odds possible toxic exposure, three types of patients pre­ that healthcare systems may be overwhelmed sent themselves for medical evaluation, (1) people (Rundell & Christopher, 2004). This chapter will with disease or injuries due to the toxic agent, © Cambridge University Press 2007 164 Management of medical and surgical disaster casualties 165 (2) people who have organic disease plus a con­ begin to present to medical facilities for evaluation ­ current psychiatric condition that may confuse the some will contract illness and some won't. The clinical picture, and (3) people who have not been experience in the United States following the anthrax exposed but fear they have. Anxiety and fear pro­ terrorism of October 2001 was that the number of voked by concerns about having been potentially people who feared exposure, or were exposed but exposed can complicate the medical picture; phy­ never developed disease, was over a thousand times siological signs of autonomic nervous system arou­ greater than the number of people who actually sal, along with normal somatizing behaviors and developed anthrax (CDC, 2001a). The ratio will dysphoria, can mimic symptoms and signs of dis­ depend on the virulence of the agent, the mode of eases due to biological and chemical agents. delivery, and the effectiveness ofrisk communication The numbers ofpeoplewho presentfor healthcare to the general public. After the clinical illnesses have in each of the three categories above are neither run their courses, there will continue to be patients proportional nor linear across the life of a bio­ presenting for health evaluations who fear they have terrorism epidemic. When there is an explosive been exposed and displaying anxiety, fear, or idio­ event, such as a suicide bombing or a building syncratic manifestations of psychiatric illnesses. bombing, physical injuries are often clear, definable, The principles presented in this discussion and in and obvious. If exposure is covert, as in potential Figure 8.1 may occur serially or continuously if release of a chemical or biological agent, patients there is an ongoing bioterrorism event (e.g., anthrax­ with organic disease will present before any wave of tainted letters mailed over several months), produ­ patients who present with fear, anxiety, or psychia­ cing waves of exposures and fear. tric illness. If a biological or chemical attack is announced by the perpetrators, the first wave of Announced exposure people presenting for health evaluation is more likely to feature behavioral manifestations, given the Some terrorists may estimate that the greatestimpact incubation periods of potential biological agents. on a population will occur if they announce they Figure 8.1 summarizes the differences between have perpetrated a bioterrorist act. An actual attack these two types of individual and community mayor may not follow. If an attack does not responses to toxic agent exposure. follow, all presentations will represent behavioral and physical manifestations of fear, anxiety, and idiosyncratic presentations of psychiatric illness. If (overt exposure an actual exposure occurs in the context of an If a terrorist group unleashes a biological agent cov­ announcement, the lengm of time for actual clinical ertly, organic disease will emerge before the general prodromes or illnesses to appear that are attributable public is aware of the terrorist event. The duration of to the agent will depend on the incubation period of the period when illnesses attributable to the agent the disease produced by the agent. Prior to the onset comprise all ofthe patients presenting or referred for cif the organic infectious disease, all patients pre­ medical evaluation depends on three variables: (1) senting to medical facilities will be people who fear the incubation period, the duration of the prodrome, exposure and might be misinterpreting signs and and the time to definitive diagnosis, (2) the length of symptoms of other physical illnesses, psychiatric time it takes public health authorities to identify a illnesses, or autonomic hyperactivity. After patients bioterrorist event, and (3) the length of time it takes stop presenting with clinical illnesses attributable to the public to be informed about the event. Once there the biological agent there will be a period during is general public awareness there has been a terrorist which the worried well or the medically ill who fear event or disaster-related release of toxic substances, their symptoms may be due to the biological agent i l people who fear they may have been exposed will continue to present, often with symptoms of fear, 166 J. R. Rundell COVERT EXPOSURE ~.----------------------------------­Time----------------------------------------------------+ Clinicall1lness Behavioral Manifestations • Clinical illness: first wave of people who present with clinical symptoms and signs of agent before the general public becomes aware of the bioterrorism event • Behavioral symptoms and signs: as the outbreak becomes defined and publicized, patients present with a mixture of clinical illness attributable to the agent, behavioral manifestations attributable to fears of having been exposed, and psychiatric disorders. After the exposures attributable to the biological agent illnesses have run their course, fears of having been exposed remain and result in continued presentations to medical facilities ANNOUNCED EXPOSURE ~-------------------------------------Time--------------------------------------------------------+ Behavioral Manifestations Clinicall1lness Behavioral manifestations: initially, the latency period and clinical course of the biological agent dictate that there has not been time yet for actual illnesses attributable to the • biological agent to have occurred. Behavioral manifestations will remain after clinical A, cases have run their course among those worried they may have been exposed fo Clinical illness: it is important to address anxiety and concurrent psychiatric disorders in • the overall medical management of patients with confirmed illness due to biological pr agents ac co Figure 8.1 Phases of individual and community responses to chemical or biological agent exposure. Adapted with eVI permission from Rundell & Christopher (2004) thl pal anxiety, or psychiatric illness: If there are ongoing or will be determined by a number of factors, listed in bel . serial bioterrorism events,. the simple curves and Table 8.1. These are a combination of individual the phases presented in Figure 8.1 may become co~Pli­ medical factors (risk factors and nature of the ill­ nUl cated, serial, and merge together into an ongoing nesses produced
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