PSB T ECHNIQUES & P ROCEDURES FOR R AD /N UC D ISASTER R ESPONSE

1. PSBTECHNIQUES &PROCEDURES FOR RAD/NUC DISASTER RESPONSE

2. VIDEO CLIP Click anywhere in frame above to view the video Excerpt from Psychological First Aid in Radiological (or Radiation) Disasters courtesy of Center for Disease Control and Prevention (CDC)

3. PSBTECHNIQUES AND PROCEDURES FOR RAD/NUCRESPONSE ● Rapid assessment, triage, & stabilization (R.A.T.S.) ● Psychological First Aid (PFA) ● Risk communication ● Conflict resolution

4. R.A.T.S.

5. RAPIDASSESSMENT, TRIAGE,&STABILIZATION Presenting Problems: ● Aggression: Can the person control violent impulses? ● Disruptiveness: Can the person regain composure and consider needs of others? ● Self harm: Does the person have active suicidal intent or exhibit behaviors involving potential risk of self harm? ● Anguish: Is the person inconsolable? ● Mental status: Does the person show confusion, psychosis?

6. RAPIDASSESSMENT, TRIAGE,&STABILIZATION Acute phase rapid assessment activities: ● Talk with the person: get information, observe - Allow the individual to tell you what is going on ● Model a calm demeanor ● Reflect understanding ● Problem-solve ● Proceed to deciding the person’s triage status

7. RAPIDASSESSMENT, TRIAGE,&STABILIZATION Deciding the person’s triage status: ● Resolved after talking ● Apply de-escalation procedures ● Remove to safety/quiet area ● Seek medical/psychiatric opinion ● Call Security

8. Rapidstabilization (and de-escalation if needed): ● May be needed for people so acutely distressed that they: - cannot function - are disruptive to others - present a direct threat to their own or others’ safety ● Strong and overwhelming emotions are often brief in duration - Give the person a few minutes of privacy to process cognitive overload and calm down – may allow episode to blow over - Tend to some nearby business, telling the person you will be available and will check back shortly to offer help RAPIDASSESSMENT, TRIAGE,&STABILIZATION

9. If possible, separate disruptive individuals to a quieter place Enlist calm family/friends to comfort distressed individuals Main interventions for acute situations: - Offer support - Focus on manageable and immediate concerns - Offer distracting and grounding techniques For very agitated individuals: - Approach calmly; invite calm discussion - Establish orientation (is the person confused/disoriented?) - Offer specific choices (behave calmly/seek higher level of assistance RAPIDASSESSMENT, TRIAGE,&STABILIZATION For anyone contemplating harm to self or others or who appears unable to control such urges, seek security and/or medical assistance immediately. Do not leave the person unsupervised.

10. DYNAMICS OF CROWD BEHAVIORS Initiation of crowd behaviors: 1) Seed: individual or small group who begins divergent activity that entices others to join in 2) Crowd engagement: others engage in the seed activities, producing the crowd behavior Examples: ● Human waves at sporting events (harmless behavior) ● Stampedes started by a few people pushing (harmful behavior) Zeitz et al 2009 Prehosp Dis Med 24:32-8

11. CROWD BEHAVIOR FLASHPOINTS ● Restriction of the flow of people  produces physical pressure points in crowds - eg, bottleneck at entrances and exits for major crowd events ● "Flight" response to a threat (either real or perceived) - eg, crowd fleeing a bomb scare ● Craze: a competitive rush to gain a highly valued goal - eg, physical competition to gain access to limited supply of life-saving antidotes Fruin 1971, Pedestrian Planning and Design, Metropol Assn Urb Designers Envir Planners, New York

12. WORKING WITH CROWDS Assessing and managing crowd behavior: 1)Assess & monitor ongoing behaviors - Warning signs: noise level (shouting), cursing, agitation (pushing, shoving, running), threats, aggression 2)Manage seed behavior - Remove negative seeds (eg, redirect to a quiet location to de-escalate) - Generate positive seeds (eg, get a group to start singing pleasant songs) 3)Inhibit harmful crowd engagement - Redirect crowd attention to positive behaviors (eg, start filling out forms; form line) - Set up & communicate ground rules – signage, announcements - Maintain visible presence of security and support staff – enforce "house rules" to discourage harmful seed behaviors from growing into collective behaviors - Know when to call Security Zeitz et al 2009 Prehosp Dis Med 24:32-8

13. SPECIFIC PSBTECHNIQUES FOR WORKING WITH CROWDS GATHERING FOR SERVICES ● Open doors to facility earlier than advertised to prevent crowd buildup ● If possible, use more than one entrance to avoid bottlenecks ● Keep crowd informed about what is going on inside the facility ● Attend to people’s basic needs and comfort while they are waiting  eg, water, restroom facilities, seating, special needs ● Train all responders in PSB techniques for working with crowds Crowd Management: Report of the Task Force on Crowd Control and Safety. Submitted to Sylvester Murray, City Manager, Cincinnati, Ohio, July 8, 1980

14. VIGNETTE A young mother who is certain she and her baby were exposed to radiation shows up at the health department seeking medical advice. She will not keep her place in line at the registration desk, pushing ahead of others. She has been asked to wait with the others, but she begins wailing loudly and shouting that if she doesn’t get her baby treated quickly the baby will surely succumb to radiation exposure. It is clear that her agitation is becoming contagious; the crowd is becoming restless. You are a public health staff person called to the scene to help: What can you do to address this situation?

15. PSYCHOLOGICAL FIRST AID (PFA)

16. PSYCHOLOGICAL FIRST AID (PFA) A form of mental health assistance provided in the immediate aftermath of disaster, to address acute distress and promote coping and functioning  Provided by mental health and other disaster response workers  Flexible for use in a variety of settings, populations, and cultures  Developed through expert consensus (PFA is intuitive and is consistent with available scientific evidence, but research to demonstrate efficacy is needed) Psychological First Aid Field Operations Guide, Natl Child Traumatic Stress Network & Natl Center for PTSD. North, Hong, Pfefferbaum 2009, Practical Front Line Assistance for Support and Healing, version 3 (P-FLASH III).

17. PSYCHOLOGICAL FIRST AID(PFA) 10 elements of PFA: 1) Being there – physical support, engagement 2)Safety and acute stabilization 3) Supportive listening & information gathering 4) Education & reassurance 5)Coping & stress management 6) Problem solving 7)Connect with support 8) Symptom management 9)Know when more help is needed 10) Caring for the caregivers

18. 1) BEING THERE Be unobtrusive, helpful, and compassionate Approach the setting first as a caring helper, not as a worker with amental health mission Be an anchor: your focused, calming presence will influence others Address immediate physical needs, comfort, and concerns This is a powerful mental health function! Your presence in itself can be comforting ("ministry of presence") Ask: “Is there anything you need?” “Is there something I can do to help you be more comfortable?” Your care for people’s needs is also a means to an end....preparatory activity to intentional mental health work (helps connect you) • Clothing – dry socks, warm shirt, blanket; food, water, coffee; kleenex; ambiance (warm/cool, dry, light/dark, clean, quiet); quiet comfortable place to sit/talk/be alone; restroom, shower; phone; medical needs, medications (don’t forget special medical needs)

19. BEING THERE.... People needing your assistance may be: - Those who seek out your help -Those who clearly need help and will tell you if you inquire - Those who do not obviously need help but will tell you if you inquire - Those who reject your help (later they may possibly be more receptive) Respect interpersonal styles (sometimes cultural) -Touch – some people find it comforting, others find it invasive -Physical distance – too close is invasive (varies by individual) -Eye contact – in some cultures, prolonged eye contact is inappropriate - Privacy and trust – some people will be slow/hesitant to open up Be sensitive to interpersonal cues about touch, distance, and privacy

20. 2) SAFETY AND STABILIZATION Protect people from further harm Attention to physical safety is actually a mental health intervention: If you can help keep people safe from physical harm they are less likely to suffer psychological trauma from that harm • Protect people from ongoing disaster-related and post-disaster hazards (such as contaminated areas, unsafe building structures, broken glass, and sharp objects)

21. SAFETY AND STABILIZATION… Protect people Protect people from other harm such as: - Exposure to traumatic images (eg, witnessing horrific scenes in the disaster aftermath) - Reminders (eg, through extensive media viewing) - Loss of privacy (eg, to media personnel, onlookers, attorneys) • Protect people from people: individual and crowd level redirection, stabilization, and de-escalation

22. 3) SKILLED LISTENING Listen to the stories with concerned interest - a mental health function Invite thoughts - gently probe for detail - don't extract unnecessary painful trauma details (follow the person’s lead; take cues from the person) - don't force feelings; let them emerge spontaneously (and prepare for intense emotions) Gather appropriate information: exposures, injuries, medical history, medications, psychiatric history

23. Varies by whether a psychiatric disorder is present or not: If NO psychiatric disorderNormalize the experience: Validate common emotional reactions Disturbing feelings don't equal mental illness ("Normal responses to abnormal events") Most people don't develop mental illness- symptoms subside with time If psychiatric disorder is presentOvercome stigma: Biological basis of persistent emotional changes and medication mechanisms Many treatment options available: treatment is effective 4) EDUCATION &REASSURANCE

24. 5) COPING & STRESS MANAGEMENT Lend permission to cry, feel bad, be nonproductive, focus on self for a period of time Regain control of some aspect; restore routine Utilize social supports Positive self talk Appropriate use of humor Self care (easy to neglect in crisis) - sleep, meals, hygiene, exercise, habits, down time, relaxation, pleasurable activities – achieve a healthy balance (avoid excesses) Active coping is the healthiest

25. Natural part of the healing process - Making meaning - Finding greater perspective in one's life Discover and respect personal values - What is important to the individual - Avoid judgment; avoid "blaming the victim" Personal roles: "victim," "survivor" - Listen to the person's language in self description Philosophy, spirituality, world view ....FINDING MEANING &PERSPECTIVE

26. ●Make a list; prioritize ●Weigh advantages and disadvantages of potential choices ●Develop more than one approach - allows a backup if Plan A doesn't work ●Try new behaviors and develop new skills ●One step at a time - manageable units first ●Keep sight of larger perspective and progress 6) PROBLEM SOLVING

27. ●Two main sources of support can help people in times of disaster: Family and friends - People who know the individual are best situated to comfort and support that person Support services (eg, social workers, medical providers, FEMA, welfare services) - Professionals have skills and resources that may help people get back on their feet ●Social supports and needed resources can go a long way toward helping people feel better ●People who lack social supports may be at increased risk for psychological adjustment problems 7) CONNECT WITH SUPPORT

28. 8)ACUTE SYMPTOM MANAGEMENT ● In the early post-disaster period, the most bothersome post-traumatic symptoms are likely to be hyperarousal symptoms:  Feeling jittery, jumpy, restless, irritable  Nervousness, anxiety, worry, fear, panic  Insomnia ● Ways to manage these acute hyperarousal symptoms:  Distraction – engage in absorbing or pleasurable activities (games, puzzles, reading, movies, social events); selective focus  Relaxation techniques – deep breathing, muscle relaxation, pre-hypnotic induction  Pharmacotherapy

29. RELAXATION: DEEP BREATHING To help people calm down or relax - good in office settings (originally used to help pregnant women to relax) or in crises Ultimate goal is to use in critical or stressful conditions – but learn it in calm situations to develop mastery Use comfortable chair, plant feet on floor, close eyes, take deep breath and hold as long as possible, then slowly exhale with suggestion: "the more slowly you let out the air the more relaxed you will feel." Practice in sets (max. 5-6) with same instructions every time (max. 2-3 times a day). Compare heart rate before and after. - For insomnia, jumpiness, hypervigilance, anger

30. MUSCLE RELAXATION Lie supine on flat surface – get comfortable, close eyes Tense one muscle group (eg, both eyes; one thigh) and hold for several seconds, then release and feel the muscles relax One at a time, systematically tense and release all muscle groups of the body (eg, head  toe) On completion, bask in the sensation of relaxed muscles Repeat as many times as desired - For insomnia, jumpiness, hypervigilance, anger

31. RELAXATION: PRE-HYPNOTIC INDUCTION Instruct individual to lie comfortably on floor, eyes closed. Read scenario in hypnotic, calm, quiet tone of voice. SCRIPT: "Imagine yourself on a beach, contemplating the clear blue water, waves slowly lapping up along the shoreline. It’s a perfect day—the air is warm and slightly breezy; the sun warms your skin. The salt air is refreshing and nostalgic. You walk to the edge of the water and scoop up some seashells. A gentle wave laps up over your hand and carries some of the smaller shells off into the ocean with it. The receding waves gently wash the sand from around your toes and you burrow them into the soft wetness again...." (and it goes on) - For insomnia, jumpiness, hypervigilance, anger

32. Indications that more help may be needed: - Intolerable symptoms persist or escalate despite interventions - Pre-existing psychiatric/substance use disorder requiring ongoing care - The person requests additional assistance - The person worries you Indications that urgent help may be needed: - The individual is too overwhelmed to be able to care for self and/or dependents (eg, stops eating/drinking; neglects child) - Indications of impending harm to self (suicidality) or others (homicidality/assaultiveness/extreme agitation) - The person cannot be oriented (eg, delirious) 9) KNOW WHEN MORE HELP IS NEEDED

33. 10)CARING FOR THE CAREGIVERS Disaster workers may themselves experience psychological distress or even become mental health casualties in difficult circumstances of disaster settings: Extended exposure to intense emotional distress Personal exposure to injury and contamination Personal exposure of self and loved ones to the disaster; worry about safety of loved ones and personal property Difficult working conditions, chaos Long work hours, cumulative fatigue Separation from usual supports and familiar comforts Ethical dilemmas

34. ...THE CAREGIVERS.... Stressors experienced by disaster workers: Exhaustion, inefficiency, loss of enthusiasm or interest for the work Diminished ability to focus and concentrate Preoccupation, inability to put thoughts and images aside, dreams of the post-disaster setting and people Guilt feelings, worry, despondency, irritability, anger Frustration (over inability to do enough; with response of leadership and authorities; with circumstances) Burnout, "compassion fatigue" Interpersonal conflict and damage to relationships

35. ADVICE FORCAREGIVER SELF-CARE First, follow the same basic advice recommended for those you are caring for (rest, nutrition, hygiene, exercise, relaxation, healthy balance) Care for your colleagues - Give them a break - Offer positive support and encouraging words - Keep an eye on their fatigue level and help them accept needed rest, nutrition, and time off Spend restorative time together (eg, breaking bread together; follow-up meetings to review the operation and work out the kinks for next time)

36. ADVICE FOR CARING FOR THE CAREGIVERS Supervisors can help disaster personnel by: distributing work loads equitably monitoring workers for signs of distress and fatigue communicating with workers to keep them informed and learn about problems/needs that arise providing encouragement facilitating opportunities for peer support providing psychological support through formal group or individual therapy

37. VIGNETTE: PFA A teenage girl is brought to the emergency department for evaluation. As soon as the nurse calls her to the exam room, she begins to panic and hyperventilate. She asks, "Am I going to die?" How can the nurse help this girl?

38. RISK COMMUNICATION

39. …in a terrorist incident involving radioactive materials, effective risk communication may be the most important way to reduce morbidity and mortality… Becker 2007 BMJ 335:1106-7, p. 1107

40. RISK COMMUNICATION A process of providing information for the purposes of reducing anxiety/fear and promoting appropriate responses to a major crisis  Communication with populations through media and in person with groups and individuals Risk communication is your job… ...it is the business of all responders

41. RISK COMMUNICATION Purpose:  Provide guidance to help people respond appropriately and safely  Offer appropriate reassurance  Inform people of what is being done for them and what are the plans People feel better and act more safely when:  they feel they know what is going on  they have confidence in the reliability of the information provided Covello et al 2001 J Urb Health/Bull NY Acad Med 78:382-91

42. KEY CONCEPTS &FACTS FOR RAD/NUC Some key concepts and facts are so basic to RAD/NUC incident response that all responders should know them  Knowing this information can help responders stay safe in the RAD/NUC response environment  Communicating this information can reassure people and help them respond appropriately and safely to their situation

43. EXPOSURE VS. CONTAMINATION ● Exposure occurs when energy traveling in waves or particles (radiation) penetrates the body (irradiation) ● Contamination occurs when radioactive material in the form of dust, powder, or liquid comes into contact with the body, and the radioactive source continues to emit radiation -External: radioactive material on a person's exterior (skin/hair/clothes) -Internal: radioactive material entered the body through open wounds, absorption through skin, mucous membranes, swallowing, or breathing

44. IMPLICATIONS OF EXPOSURE VS. CONTAMINATION ● People who have been exposed/irradiated (without contamination) are not radioactive For example, having an X-ray taken, which exposes you to radiation, does not make you radioactive ● Contaminated people have loose particles of radioactive material (dust/dirt) that emit radiation and may be spread to contaminate others and the environment Decontamination should be done as soon as possible Contamination is easily removed by changing clothes and showering (use simple soaps and don't abrade skin)

45. RESPONDERS:DON'T FREAK OUT Addressing contamination issues should not delay treatment of life-threatening injuries ● Externally exposed patients do not become radioactive - Not a radiation risk to medical responders ● Levels of radioactivity emitted by patients with external or internal contamination are unlikely to cause medical harm to care providers - Decontaminate external contamination as soon as possible without delaying critical care (use respiratory precautions) Centers for Disease Control and Prevention 2005. Radiological Terrorism: Emergency Management Pocket Guide for Clinicians. http://www.bt.cdc.gov/radiation/pdf/clinicianpocketguide.pdf

46. 3FACTORS DETERMINE EXPOSURE ● TIME: The more time you spend near the radiation source, the greater your exposure will be ● DISTANCE: The closer you are the source, the greater your exposure will be - Radiation exposure decreases with distance according to the inverse-square law: if you triple your distance from a radiation source, your exposure decreases by a factor of 9 (ie, 32) ● SHIELDING: The greater the shielding between you and a radiation source, the less you will be exposed - Lead and concrete are best, but staying behind vehicles, buildings, or other objects can also decrease exposure US Environmental Protection Agency 2010. Radiation Protection Basics. http://www.epa.gov/rpdweb00/understand/protection_basics.html

47. FRIENDLY FACTS FOR NUKES ● Immediately after a nuclear detonation, the safest action is to seek shelter for 24 hours in a location deepest within the biggest building that has the thickest brick, stone, or concrete walls (wood and thin metal are not as good), or underground - Eg, optimal location within a large solid building can reduce exposure by a factor of 50 (being in a vehicle provides little fallout protection) - This is why immediate sheltering in place can be far safer than evacuation ● A "dirty bomb" is not a nuclear bomb and causes far less destruction and injury - The greatest harm is likely to be from the explosion itself Homeland Security Council 2009. Planning Guidance for Response to a Nuclear Detonation. http://bit.ly/aeVGl2

48. RISK COMMUNICATION FOR RAD/NUC Acute risk communication needs in RAD/NUC incidents 1. Immediate population safety  Eg, after nuclear event: shelter in place – "Get inside NOW!" 2. Surge prevention  Providers of medical care and information become overwhelmed - Cesium-137 incident killed 4 in Goiânia, Brazil in 1987: 112,000 people sought radiological monitoring in special facilities  Highways become clogged after nuclear event - Three Mile Island:for every person asked to evacuate, 45 did (150,000 in all) Collins & Carvalho 1993 Behav Med 18:149-57; International Atomic Energy Agency 1988. The radiological accident in Goiania, STI/PUB/815. Vienna: IAEA; Erickson 1994, A New Species of Trouble: The Human Experience of Modern Disasters, New York: Norton

49. RISK COMMUNICATION: GETTING STARTED  A two-way communication process  Start by soliciting and listening to people’s specific concerns  Respond with timely & regular updates  Concerns to expect based on experience and research  Personal safety ● How to keep my self / family / pets safe? ● Where should I go to be safe? How can I avoid exposure?  Health ● How do I know if I have been exposed? ● What symptoms should I look for? ● How (and when) can I get tested? ● What will they do if I have been exposed? ● What effects will I have short/long term if I have been exposed?

50. HAVE MESSAGES READY Having a repertoire of audience-tested, scientifically grounded prepared messages available means that vital information can be released almost immediately Types of messages to have ready for RAD/NUC incidents ● Seek safety (eg, shelter in place) ● Stay put: shelter in place until radiation subsides ● Determining one's exposure ● Health measures to take (eg, decontamination) Becker 2004 Biosecurity & Bioterrorism 3:195-207