Resiliency in the Face of Disaster and Terrorism 10 Things to Do to Survive V. Alex Kehayan, Ed.D. and Joseph C. Napoli, M.D.
A Pocket Guide
Resiliency in the Face of Disaster and Terrorism 10 Things to Do to Survive Copyright © 2005 by V. Alex Kehayan and Joseph C. Napoli All rights reserved. No part of this book may be used or reproduced in any manner whatsoever without written permission from the publisher and authors except in the case of brief quotations embodied in critical reviews. Queries regarding rights and permissions should be directed to the publisher. Published by Personhood Press P.O. Box 370 Fawnskin, CA 92333 800-429-1192 Email:
[email protected] Website: www.personhoodpress.com ISBN: 1-932181-18-0 Book and Cover Design by Christine Scharch of Tupelo Art Printed in the United States of America Library of Congress Cataloging-in-Publication Data.
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To all the survivors with whom
we have had the privilege of working
Foreword Prior to September 11, 2001, Americans defined disasters in terms of nature, traffic accidents, or domestic crime. Terrorism, war, even the threat of large scale horrors, were calamities to be feared by the rest of the world, tragedies that fell upon other people. They were not anything we needed to realistically fear here in our United States. But on that Tuesday morning, we learned most personally that disaster – terrifying, unexpected, violent tragedy – does not only happen to someone else. It can happen to anyone. It happened to me. On 9/11/2001, my husband John was among the nearly 3,000 people killed when terrorists crashed their airplanes into the World Trade Center. My world, my children’s world, our nation’s world changed forever that day. It has not been, nor will ever be the same. As a result, we as a nation are left feeling vulnerable and afraid. How are we to wake up and face each day confronting our frailty, our mortality, the real chance that a disaster can affect us personally? How can we be resilient? How can we enjoy the beauty of life amidst the threat of danger? How can we rise above the fear? It has not been an easy task for my children or me. We are not blessed with the ability to turn our faces away from the tragedy. We cannot pretend it did not happen, or find a sort of solace in the fact that we were spared and might continue to be spared. John is forever gone; the violent circumstances of his death firmly and forever imbedded in our minds and hearts. “An ounce of prevention is worth a pound of cure.” A simple adage, but a rule to live by. This plain sentence is a priceless tool for all of us as we strive to be resilient in an vii
unsettled world. Many people believe that explaining or discussing possible threats, risks, and after-effects of disaster does nothing more than incite increased fear. Yet, as evidenced by the world-wide campaigns for self care and examination, and disease prevention, it is clear that the MORE information to which an individual has access, the MORE prepared he will be, and therefore, the LESS risk he will face in almost every situation. Information REDUCES fear. A future fraught with its share of adversity, but adversity for which one is prepared, is a future that holds less risk of tragedy. We are human, and events like 9/11 remind us we are fragile and vulnerable. This book, Resiliency in the Face of Disaster and Terrorism: 10 Things To Do To Survive, by Dr. Joseph Napoli and Dr. V. Alex Kehayan, can be your tool, your source of information to be best prepared should disaster find itself at your front door. Both authors have seen the effects of fear in disaster survivors and in their patient populations, and have dedicated themselves, through this book, to help even more people fight the fear associated with today’s world. They present their outreach experience and clinical expertise in such a way as to be most useful for everyone, including attention to special needs issues such as caring for children and seniors. This book offers information as well as instructions on how best to prepare yourself for the future and how best to strengthen your own resiliency.
MaryEllen Salamone President Families of September 11
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Preface Childhood trauma. Domestic violence. Fires. Homicide. Industrial accidents and disasters. Motor vehicle accidents. Natural disasters. Rapes. Suicides. Terrorism. Transportation disasters. Violence. Genocide. War. We have worked with survivors who have faced a multitude of traumatic events. We have witnessed the resiliency of many survivors. We give you the benefit of our expertise derived from many years of experience, and share what we have learned from the survivors of disaster and terrorism. Our book condenses the essential collective knowledge in the fields of disaster mental health, emergency management, and public health. This simple, practical pocket guide will assist you – the general reader – to be a more resilient and effective disaster survivor. It will describe how you can help yourself and others in your community to carry on. Alex & Joe
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Disclaimer This is merely a guide. We do not make any claim that the material contained in this book will guarantee a positive outcome. Rather, if applied correctly and in an appropriate situation, it can reduce the chances of a negative outcome. Your knowing and applying these guidelines does not make you an expert. Furthermore, the information we provide does not replace the use of good judgment in any particular circumstance. If you have any question or concern, you should not hesitate to seek professional help, especially, if you or someone else needs medical attention, or needs to take action regarding someone’s potential dangerousness. In particular situations, we advise that you seek advice from an appropriate health professional, mental health professional, law enforcement officer, or other expert. The authors and publisher shall have neither liability nor responsibility to any person or entity with respect to any loss or damage caused, or alleged to have been caused, directly or indirectly, by the information contained in this book. The knowledge we are providing is based on observable data, expert consensus, and/or the latest research findings as of the time that the book goes to press. At present it is the best practice available. However, new research and the accumulation of new knowledge may alter these practices in the future. We have attempted to confirm the accuracy of the information set forth herein. Just before the book’s publication, we again checked the websites, telephone numbers, etc. of the resources that we have listed. Since such information is apt to change, we recommend that you periodically check it. By updating this information, as necessary, you will keep your guide up-to-date and always ready to use. We do not vouch for the accuracy or completeness of any information obtained from outside sources. For information we have obtained from outside sources, we have, to the best of our abilities, accurately communicated that information, but we have not verified whether the information obtained from those sources is true, accurate, or complete. Every effort has been made by the authors to respect gender sensitivity, honor different cultures, and avoid biased language. However, for simplicity of style, and clarity of expression, we have taken the liberty to alternate the use of gender specific pronouns where the content or an antecedent did not require the use of the masculine or feminine pronoun. You may substitute the pronoun of the opposite gender in each instance where we have alternated gender pronouns.
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Contents Foreword
vii
Preface
ix
Introduction
1
1. DETERMINE WHAT MIGHT HAPPEN
5
2. LEARN WHAT TO EXPECT
16
3. PREVENT
29
4. PREPARE
52
5. LEARN HOW WE REACT
76
6. DECIDE WHEN TO GET HELP
101
7. SEEK HELP
126
8. HELP YOURSELF
141
9. HELP OTHERS
164
10. DO 1 TO 9
185
Appendix
187
Things to Do for Any Disaster
187
Disease Outbreaks: Causative Agent, Transmission, Symptoms, and Things to Do
188
Things to Know for Chemical Terrorism
189
Things to Know for Bioterrorism
190
Learn More About It
191
Acknowledgments
194
About the Authors
xi
Introduction “Of a good beginning cometh a good end.” John Heywood 1546
Why a guide about survival? We have produced this guide because disasters challenge our survival. How do we survive? We stay alive. We continue to function as individuals. We carry on as a society. The definition of disaster by the World Health Organization (WHO), as “a severe disruption – ecological and psychosocial – which greatly exceeds the coping capacity of the affected community,” addresses the twofold dimension of disaster. On the one hand, a disaster is a massive event that causes death and destruction. On the other hand, a disaster tears the social fabric, disrupting our human bonds and leading us to question the meaning of life. Disasters can injure our psychological functioning and test our ability to cope. Although the pocket guide emphasizes disasters, it does not neglect crises, that is, everyday tragedies, or “personal disasters,” that individuals and their loved ones try to endure. Both crises and disasters are psychosocial events that involve a threefold individual reaction. We react biologically. We react psychologically. We react as members of society. However, for convenience, we will use the term “disaster” throughout this guide instead of using “crisis” and “disaster.” What about resiliency? Because we are mental health professionals, we focus primarily on your psychological survival. We believe that giving you knowledge about disasters and a set of practical tools strengthens resiliency, that is, the capacity to “bounce back.” We give you tips on how to cope, 1
conquer, adapt, and re-equilibrate (regain your balance and return to pre-disaster functioning or create a new level of functioning). We help you to move on, so you are not a victim of life’s catastrophic events but a survivor. We emphasize the importance of respecting cultural differences when helping others to survive disasters. Since disasters also threaten life and limb, we also emphasize what you can do to prevent death and bodily injury. We highlight the importance of safety and preventive measures. We outline specific actions that you should take to protect yourself and others. Even those methods that may not appear related to psychological wellness are actually basic to maintaining your emotional well-being. By being prepared and knowing what to do in the face of danger, you can eliminate the irrational fear that leads to panic. By knowing the ten basic things to do, you can act confidently and decisively. What are the 10 things that you should do? You should do the following: 1) determine the types and frequencies of the disasters that might happen, especially in your community, 2) learn what to expect when a disaster strikes, 3) prevent disasters or lessen their impact, 4) prepare for disasters, 5) learn the human reactions to disaster, 6) decide when you need to seek help, 7) find out where to get help, 8) help yourself, 9) help others, and 10) convince yourself that doing the first nine things is essential for your survival and the survival of others. In this time of terrorism, Homeland Security Advisory System alerts, Center for Disease Control and Prevention bulletins about new disease outbreaks, and daily media barrages with the latest news of violence and tragedy, convincing yourself to use this pocket guide should not be difficult. Do 2
we want to make you anxious? Yes we do! A little bit of anxiety is a good thing. It keeps us vigilant and ready. Nevertheless, too much anxiety interferes with our attention and ability to function. Therefore, when fear seems to dominate everyday life, we believe that you need to assess risk, maintain a proper perspective, and manage your fear. This book helps you manage your fear in two ways – it provides you with fear reduction strategies, and as a pocket companion, it puts essential information at your fingertips. In the words of Sir Francis Bacon, “Knowledge is Power.” Disease outbreaks have occurred throughout history. Although the particular infectious agents may be new and the disease names – HIV, West Nile, SARS (Serious Acute Respiratory Syndrome) – may be recently coined, large disease outbreaks have always plagued mankind. Pestilence has always created the largest disasters. The wrath of Mother Nature – volcanic eruptions, earthquakes, floods, tornadoes, tsunamis – is very violent and more dramatic, but her stealth invaders, especially bacteria and viruses, are more deadly. In the Middle Ages, bubonic plague killed a third of the world’s population. The estimated worldwide death toll of the great influenza pandemic of 1918 was at least 50 million and possibly as high as 100 million people. Therefore, we tell you things to do when there is an outbreak of disease. Some believe “no pain, no gain.” We reject this myth. Although disasters cause sorrow and emotional pain, we do not believe that severe suffering is necessary for psychological development. Enduring torment is only one path to personal growth. Therefore, you need not fear that recovery from a disaster will only occur if you embrace suffering. We prefer to place our reliance on the resiliency of the human spirit. Although we confront you with catastrophe and violence, 3
our message is one of hope. It is our wish that by using this guide you will not be a victim of a disaster but a survivor who may even grow from the experience. Although some of the practical steps are geared to the United States, the many principles that we present are universal and may be applied anywhere in the world. Most private agencies listed in this guide are committed to global disaster relief. Our descriptions of governmental disaster preparedness, response structures, and programs in the United States illustrate the role of governments in countries throughout the world in helping their citizens survive disasters. How does our guide’s design help you? Simply put, it is user friendly. Our chapter title pages give you the main points and subject areas of each of the 10 things to do, so you can go straight to the parts that you want to pursue. We use a bullet format to emphasize things to learn, lists to remember, and the best actions to take. Our “Do You Know?” sections alert you to special topics. Boxes highlight important procedures and specific organizations that provide help. Other information is organized in tables for handy reference. You can make enlarged copies of forms and kit checklists and use them as part of your Family Emergency Preparedness Plan. Read this guide. Digest its information. Carry it with you. Be prepared. Use your power to face traumatic events. Then you will be able to meet the challenge of disasters and help yourself and others to be resilient.
4
DETERMINE WHAT MIGHT HAPPEN
FREQUENCY OF EVENTS IN THE UNITED STATES p. 7 FREQUENCY OF EVENTS IN THE WORLD p. 9 NATURAL DISASTERS AND EMERGENCIES p. 10 CYBER INCIDENTS p. 13 CBNRE (CHEMICAL, BIOLOGICAL, NUCLEAR, RADIOLOGICAL, AND EXPLOSIVE AGENTS) p. 13
5
What Might Happen
1
WHAT MIGHT HAPPEN “We didn’t start the fire/ It was always burning/ Since the world’s been turning” Billy Joel 1989
In general, we should take an all hazards approach and be prepared for any disaster at any time. Nevertheless, it is advantageous to know the potential for specific events. In order to prevent, it helps to know what we are preventing. In order to be ready, it is best to be specific with our preparations. Therefore, it is important to know what disasters might occur, especially those that might typically occur in your community. What is the risk of a particular traumatic event occurring? Which ones are more likely to occur? Which ones are less likely to occur? How frequently do particular events occur? How deadly and devastating are they? By answering these questions, we are able to better prevent and prepare. Below we provide partial lists of disaster or emergency events that occur respectively in the United States and in the world (including the United States). For comparison, we have also included some non-disaster events such as fatalities due to cancer or poverty. We present this data as approximate frequencies, which are more dramatic than statistical measures of percentages, risk ratios, and the number per 100,000 of the population. However, bear in mind that these events do not necessarily occur at regular intervals. The frequency method spreads the events out over an entire year even though they might have occurred in clusters within a year. 6
FREQUENCY OF EVENTS IN THE UNITED STATES
On average, every: 1.6 seconds a person experiences a disabling injury due to an accident 2.5 seconds a person experiences a heart attack 4.7 seconds an acre of forest is destroyed by wildfire 5.0 seconds a motor vehicle accident occurs 6.3 seconds a woman is the victim of domestic violence 7.7 seconds a person experiences a workplace injury 9.9 seconds a person experiences a motor vehicle accident injury 44.5 seconds a person dies from heart disease 57.3 seconds a child is neglected 57.3 seconds a person dies from cancer 1.2 minutes an elderly person is abused 1.3 minutes a tobacco related death occurs 1.6 minutes a child is abused 1.8 minutes an obesity related death occurs 2.6 minutes a woman is raped 2.6 minutes a person is hospitalized for influenza 4.4 minutes a pregnant woman is involved in a motor vehicle accident 5.2 minutes an alcohol related death occurs 5.3 minutes a thunderstorm occurs 5.8 minutes a person is injured during a tornado 6.8 minutes a wildfire ignites 9.7 minutes a person dies due to an accident not involving a motor vehicle 7
What Might Happen
For example, several civilians might have died during a single terrorist attack, but these fatalities are accounted for as if they occurred over time.
12.3 minutes a person dies due to a motor vehicle accident 13.1 minutes a person becomes infected with HIV 13.1 minutes a person dies from influenza 15 minutes a fire breaks out 18.2 minutes a person is shot to death 18.6 minutes a person commits suicide 18.8 minutes a person is injured in a fire 32.7 minutes a homicide is committed 34.5 minutes a person dies from HIV 35 minutes an alcohol related motor vehicle death occurs 43.8 minutes an emergency vehicle accident occurs 1.3 hours a candle ignites a fire 1.6 hours a person dies in a fire 1.6 hours a boating accident occurs 1.7 hours a person dies due to a workplace accident 2.4 hours a person dies due to a motorcycle accident 2.5 hours an earthquake occurs 18.3 hours a fetus is killed due to a motor vehicle accident 13.7 hours workplace violence occurs 1.1 days a railroad crossing fatality occurs 1.2 days a person is injured by lightning 1.7 days a person dies due to a thunderstorm 1.9 days an explosion occurs 2.6 days a person dies due to a flash flood 3.7 days a person dies due to lightning 11 days a child is shot to death 11 days a person dies in a landslide 33.2 days a major landslide occurs 34.7 days a person dies due to an aviation accident 8
(In stark contrast to the above events, there has been only one major nuclear power plant accident which occurred in 1979. Also, twenty-two individuals were infected and five died during the anthrax terrorism in 2001.)
FREQUENCY OF EVENTS IN THE WORLD
On average, every: 1.1 seconds a person is injured in a motor vehicle accident 2 seconds a thunderstorm occurs 3.6 seconds a person dies because of poverty 11.3 seconds a person dies from HIV 17.3 seconds a child dies from malaria 26.3 seconds a person dies due to a motor vehicle accident 60 seconds a person dies due to interpersonal violence 1.7 minutes a person dies in an armed conflict 1.8 minutes a woman is raped 8.4 minutes a person dies due to a disaster 16.9 minutes an earthquake occurs 3.2 hours a person dies due to an aviation accident 9
What Might Happen
91.3 days a fatal train wreck occurs 162.3 days an aviation disaster occurs 182.6 days an act of international terrorism occurred (1991 to 2000) 219 days a hurricane occurs 219.2 days a school shooting involving mass casualties occurs 260 days a person died due to an act of international terrorism (1991 to 2000) 365 days a nuclear power plant accident occurs
3.8 hours a civilian dies due to terrorism 23.1 hours a terrorist incident occurs 3.6 days a hurricane occurs 7.1 days a volcano erupts 15.4 days an aviation accident occurs (The approximate death toll from the 2004 Asian tsunami was 173,906 compared to an estimated 1,825,000 children who die from malaria each year.)
NATURAL DISASTERS AND EMERGENCIES Avalanches: An avalanche occurs when a mass of snow breaks loose from a mountainside. It can travel at speeds over 200 mph (322 kmph).
Droughts: A drought is a prolonged period of drier than normal weather. The US Weather Service defines a drought as at least 21 consecutive days of 30% or less of the average rainfall for a particular area and season.
Earthquakes and Tsunamis: An earthquake is the powerful shaking of the earth caused by the release of pressure that has built up as two large sections (tectonic plates) of the earth’s crust grind against each other along a fault line. The amount of ground movement is measured using the Richter scale devised in 1935 by geologist Charles Richter. A tsunami, a Japanese word meaning “harbor wave,” is a wave triggered mostly by an undersea earthquake. The wave grows to tremendous size (up to 90 feet in height) as it travels at speeds of up to 398 mph (640 kmph) and can reach several miles inland. Alaska, California, Hawaii, Oregon, and Washington are states that have experienced tsunamis.
Extreme Heat: Heat waves – prolonged high environ10
Floods: Floods can be caused by heavy rains, hurricanes, melting snow, collapsing dams, etc. and account for over 40% of natural disaster deaths worldwide.
Hurricanes (tropical cyclone): A hurricane is an intense tropical circulating weather system. The word hurricane is from Mayan and Crib Indian roots and means “evil spirit,” “storm god,” or “devil.” Hurricanes are classified using the Saffir-Simpson Scale devised by Herbert Saffir, an engineer, and Dr. Robert H. Simpson, former director of the National Hurricane Center, that ranks hurricanes according to degree of damage and rate of sustained winds. Less intense tropical circulating weather systems are termed tropical depressions and tropical storms. A storm surge is a large wave of water between 50 to 100 miles wide that moves across the coastline where a hurricane makes landfall. A storm tide is a storm surge combined with the normal tide. Therefore, when a storm surge occurs during high tide, the height of the water is even greater. The storm tide of Hurricane Camille in 1969 was 25 feet high. Hurricanes can grow to 500 miles in diameter. The hurricane season starts in June and extends through November. It peaks from midAugust to mid-October. The Atlantic and Gulf coastal states, and the Caribbean islands are at risk. In the Pacific Ocean, Hawaii, Guam, American Samoa, and other islands are at risk. In the western pacific, these weather systems are called typhoons. They are referred to as cyclones when they strike the coastlines along the Indian Ocean.
Landslides and Mudslides: These are movements of 11
What Might Happen
mental temperatures – create emergency conditions because they can cause illness and death, especially in the elderly, young children, and those who are ill or overweight.
huge masses of earth that may travel at speeds in excess of 200 mph. Earthquakes, heavy rain, and construction can trigger them. Sinkholes are horizontal depressions in the ground that develop suddenly and rapidly due to the loss of underground support.
Thunderstorms and Lightning: These storms, which cover a small area compared to hurricanes and winter storms, can cause severe flooding and lightning damage. A thunderstorm is described as “severe” if it produces either hail at least three-quarter inch in diameter, winds 58 mph or higher, or tornadoes. Lightning can occur anywhere, anytime, and without any rain. Thunderstorms are most likely to occur in the spring and summer, but can occur all year round.
Tornadoes: Tornadoes are rotating columns of air that extend from swelling cumulonimbus clouds to the ground. Although 40% of the tornadoes in the United States occur in the central plains states from March through July, they can happen anywhere. More tornadoes touch down in the United States than any other country.
Volcanic Eruptions: There are about 600 active volcanoes or vents through which molten rock escapes from beneath the earth’s surface. Many erupt periodically without any threat to human life or property. Some volcanoes produce a continuous lava flow; others cause powerful explosions that hurl ash and volcanic fragments into the sky. After being dormant for 123 years, Mount St. Helens in Washington state erupted on May 18, 1980, producing an ash cloud fifteen miles high, causing 60 deaths, destroying 123 homes, and devastating tens of thousands of acres of forest.
Wildfires: These fires can spread rapidly, setting brush and trees ablaze, and leaving the earth scorched. Wildfires 12
Winter Storms and Blizzards: Blizzards consist of sustained winds or frequent gusts to 35 mph or greater and considerable falling and blowing snow that reduces visibility to less than a quarter mile. In March 1888, a blizzard devastated the coastal northeastern United States from Washington, DC to Maine and probably caused about 800 deaths.
CYBER INCIDENTS Cyber (computers and their support systems) incidents could be caused by natural disasters which could damage or destroy equipment. In addition, financial, security, and transportation information systems could be disrupted or destroyed by the introduction of computer viruses or worms. An intruder could hack into a computer system and take it over.
CBNRE (CHEMICAL, BIOLOGICAL, NUCLEAR, RADIOLOGICAL, AND EXPLOSIVE AGENTS) Chemical: There are four categories of chemical weapons: 1) blister agents: used to incapacitate by producing eye, skin, and respiratory irritations and pain (mustard agents, Lewisite, and phosgene oxime), 2) blood agents: used to cause death by destroying tissues, thereby causing breathing to stop and cardiac arrest (hydrogen cyanide and cyanogen chloride), 3) nerve gases: used to block nerve functioning and cause convulsions and death (Tabun, Sarin, Soman, and VX), and 4) lung toxins: used to damage the 13
What Might Happen
cause an average loss of 2 million acres a year in the United States. Hot summers produce tinder-dry conditions that leave the countryside vulnerable to accidental or deliberate man-made fires. Dwellings near wooded areas can easily be engulfed in the flames of an advancing wildfire.
capacity to breathe (phosgene and diphosgene). In addition, conventional explosives could be used to damage a chemical plant and cause clouds of hazardous materials to disperse over the surrounding population. Disasters involving hazardous chemicals may also occur by accident during the manufacturing process or while the chemicals are being stored or transported.
Biological: Although there are numerous infectious agents, the most likely biological agents that would be used are rated by the CDC as highest risks (category A). They are anthrax, botulism, plague, smallpox, T2 mycotoxins, tularemia, and viral hemorrhagic fevers. Secondary agents include brucellosis, glanders, melioidosis, psittacosis, Q fever, ricin, and staphylococcal enterotoxin B.
Radiological: A dirty bomb or Radioactive Dispersal Device (RDD) is a bomb made of conventional explosives contaminated with a small amount of radioactive material. When the bomb is detonated (most likely in a crowded area), the explosion would cause structural damage and human injuries, deaths in the adjacent area, and spew out radioactive material so that it contaminates people over a wider area. Radiological events could also occur by accident within industrial, medical, or research facilities or during the transportation of radioactive material or waste. However, the handling and transportation of radioactive material is so highly regulated and safeguarded that these events are of low frequency and/or intensity. Since conventional explosives and radioactive material and waste are plentiful, a dirty bomb scenario is very likely.
Nuclear: Two possible nuclear scenarios are: 1) a terrorist piloted plane or planes carrying explosives could crash 14
Explosives: Conventional explosives are the most likely type of terrorist weapon. The ingredients are inexpensive, readily available, and easily assembled. Presently, this is the most widely used method and includes the use of suicide bombers, especially in crowded areas or on public transportation. In the United States there have been terrorist bombings of cars and buildings. The Unibomber killed his victims by sending bombs through the mail. The first attack on the World Trade Center on February 26, 1993, and the bombing of the Murrah Federal Building in Oklahoma on April 21, 1995, used bombs made of fertilizer that were carried respectively in a van and a rental truck. Other terrorist bombings include: the Fraunces Tavern in New York City that killed four and injured sixty by the Armed Forces of the National Liberation (Fuerzas Armadas de Liberacion Nacional (FALN)) on January 24, 1975, and the US Department of State building in Washington, DC on January 29, 1975 by the Weather Underground Organization during the Vietnam war.
15
What Might Happen
into a power plant nuclear reactor causing an explosion and damage that allows radioactive gases to spew from the plant, and/or 2) a small nuclear device or portable bomb could be detonated in a crowded area. Fortunately, although such bombs exist, experts believe that terrorist groups do not presently possess them. Nuclear power plant events may occur by accident. Two notable nuclear power plant accidents occurred at Three Mile Island, Harrisburg, Pennsylvania on March 28, 1979, and at Chernobyl in the former USSR on April 25-26, 1986.
2
LEARN WHAT TO EXPECT
FOR ANY TYPE OF DISASTER (ALL HAZARDS) p. 17 Before a Disaster (Warning Phase) p. 17 Immediately after Impact (Response Phase) p. 18 Over Time after a Disaster (Recovery Phase) p. 19 SPECIFIC CONSEQUENCES OF PARTICULAR TYPES OF DISASTERS p. 20 Disease Outbreaks p. 20 Natural Disasters p. 21 Other Disasters p. 21 Terrorism p. 21 GROUPS WITH SPECIAL NEEDS p. 23 Children p. 23 Physically Disabled p. 24 People with Serious Mental Illness p. 24 Seniors p. 24
DO YOU KNOW? Disaster Phases p. 25 Response Sequence p. 27
16
LEARN WHAT TO EXPECT “If anything can go wrong, it will.”
In this section we describe the details of what a disaster could possibly do to your community before, during, and after it strikes. Chaos is the essence of any disaster because existing social structures and infrastructures are destroyed. Even carefully planned responses by emergency workers are often frenzied. The degree of chaos is proportional to the magnitude of the disaster. However, even a disaster of low magnitude may be experienced subjectively as extremely chaotic. First, we present a general list of things to expect that apply to all hazards. Although chaos is part of any disaster, the specific things that might go wrong are largely dependent on the type of event, its intensity and size, its duration, its location, how many people are involved, and what is impacted. Then, we list specific consequences that are associated with particular disasters.
FOR ANY TYPE OF DISASTER (ALL HAZARDS) Before a Disaster (Warning Phase) For events for which there can be warnings, there will be: Public broadcasts of public advisories and warnings Excited and anxious people Increased activity Increased traffic and traffic jams Shopping for water, food, and emergency supplies 17
What To Expect
Murphy’s Law
Evacuation routes bumper-to-bumper, if authorities order an evacuation Roads and areas closed by law enforcement personnel
Immediately after Impact (Response Phase) Chaos! Chaos! Chaos! Damage and destruction Disruption of transportation roads and bridges blocked, damaged, or destroyed grounding of air travel Hazardous material conditions Lack of water contaminated water disruption of water supply Loss of communications including: cellular phones emergency communication systems pagers pay phones radio and/or TV transmission telephones Mass casualties and injuries Outbreaks of fires Power outages causing loss of: air conditioning 18
ATMs computer (automated data processing) systems unless battery operated backup electric appliances including microwave ovens and electric stoves
lights including street lights refrigeration television and radios unless battery operated traffic signals water for people who use well water obtained via electric pumps
Over Time after a Disaster (Recovery Phase) Economic hardship Health hazards and disease Huge financial cost for reconstruction Increased prices because of shortage of goods due to crop damage, disruption of production, and/or increased demand People dislocated Waste accumulation due to: disruption of garbage collection spoiled food sewage processing plants unable to operate
19
What To Expect
heat
SPECIFIC CONSEQUENCES OF PARTICULAR TYPES OF DISASTERS Disease Outbreaks The course and speed of a disease outbreak depends on opposing forces. On the one side, the factors are lethality of the biological agent (virulence), disease transmission, environmental conditions, such as overcrowding or poor sanitation, and human behaviors that might enhance the transmission of the disease. On the other side, working against the spread of disease are countermeasures such as public health surveillance, immunization, changes in human behavior, medication, and quarantine, that is, isolating infected individuals so that they will not infect others. An epidemic can be prevented or controlled by public health measures such as educating the public, promoting sanitary conditions, reporting and tracking of new cases, and reducing the populations of disease carrying animals (vectors). SARS (Serious Acute Respiratory Syndrome) is an example of a relatively contained disease outbreak. From November 2002 through June 12, 2003, SARS, a potentially severe form of pneumonia, infected 8,500 and caused about 800 fatalities worldwide. It is believed that this illness started in China and was identified in Vietnam in February 2003. In July 2003, the World Health Organization (WHO) declared the end of the global outbreak. In contrast, malaria is still a huge health menace in underdeveloped countries. Although the annual influenza outbreak is small compared to the influenza pandemic of 1918, influenza still causes about 36,000 deaths each year in the United States.
20
Natural Disasters Geological and weather events may range from those that inflict little or no damage on people and their living environment to disasters that cause mass casualties, widespread devastation, and billions of dollars in losses.
Industrial disasters may involve fires and explosions that cause the release of hazardous materials into the air, necessitating the evacuation of the surrounding areas. Transportation disasters – motor vehicle accidents, aviation disasters, naval disasters, train wrecks – may involve many people and result in mass casualties, hazardous material spills and fires. Trapped individuals will need extrication.
Terrorism Cyber Terrorism corruption of data files disruption of information systems disruption of banking, transportation and/or utilities disruption of the availability of food and pharmaceuticals disruption of government operations impact on economy CBRNE Agents
Chemical: People contaminated by a chemical agent would become sick immediately. The degree of illness would 21
What To Expect
Other Disasters
depend upon the type of chemical and degree of exposure. The number of casualties would depend on the agent, the amount released, the number of people exposed, and the area in which it was released, for example, indoors or outdoors. Hazardous material units would respond, set up decontamination facilities, and decontaminate people. Decontamination would also take place in facilities set up adjacent to hospitals.
Biological: There would usually be no awareness of an attack until several days after the release of the biological agent. The first reported symptoms would not likely be recognized as terrorist related. As the number of individuals reporting similar symptoms increases, public health surveillance methods would detect the surge of cases, and bioterrorism would be suspected. An investigation would be launched to determine the origin of the illness. As more individuals become ill and require treatment, an even larger number of people may become exposed and need preventive interventions. Treatment centers, called points of distribution (POD), would be set up in various locations and staffed by health personnel to distribute antibiotics or administer vaccinations. The National Pharmaceutical Stockpile would provide medication and vaccines to augment the local supply. [See “Do You Know?” “National Pharmaceutical Stockpile” in Chapter 4, p. 72.]
Radiological/nuclear: The degree of destruction would depend upon whether a nuclear device is detonated (mos destructive/very high radioactivity), a dirty bomb is exploded (destruction depends on amount of explosives/ not much radioactivity), or a nuclear power plant is attacked (not much destruction outside the plant/could be high radioactivity). A detonated nuclear device would be very devastating. There 22
Explosives: The number of injuries and fatalities and amount of property damage would depend upon the amount of explosives, where they were placed, how many people were in the vicinity, and whether the explosives were detonated out in the open (less impact) or in an enclosed area (greater impact).
GROUPS WITH SPECIAL NEEDS There are individuals in certain groups that have special needs compared to others in the general population. In this chapter, we highlight these groups by listing the possible additional disruptions and environmental changes that might impact them. In subsequent chapters, we describe other aspects about these groups specific to those chapter topics.
Children Compromised school operations Disruption of activities outside of school 23
What To Expect
would be a powerful shockwave causing buildings to implode and generating a wind that would demolish structures and forcefully propel people and objects. Intense heat and light from the thermal radiation would burn and blind people and ignite fires. The electromagnetic pulse (EMP) would destroy all electronic circuitry so that cars, computers, and communication equipment would not function. People exposed to a high level of radiation would develop acute radiation sickness (ARS), causing serious tissue damage and producing symptoms within minutes or hours. Those who survived the nuclear blast would probably have about a 15% increased risk of developing cancer over the long term.
Physically Disabled Disruption of service delivery Destruction of the usual accessible environment
People with Serious Mental Illness Disruption of service delivery: Service center, such as the Community Mental Health Center, is impacted by the disaster. Provider resources are diverted to emergency services for disaster victims. Changes in the environment: Client cannot get to service center because public transportation is disrupted. Stabilizing psychiatric medications become unavailable.
Seniors Disruption of service delivery: The senior center is impacted by the disaster and cannot provide services such as meals and health clinics. Health center services are disrupted or diverted to care for disaster victims. Changes in the environment: Client cannot get to service center because public transportation is disrupted. Disease stabilizing medications become unavailable.
DO YOU KNOW? 24
DO YOU KNOW? Disaster Phases Do you know the different phases of a disaster?
Mitigation: Before or in between disasters, we take steps to prevent or lessen the impact of potential disasters. For the community, this might consist of the government establishing a water control project to reduce the possibility of flooding. For a family, this might be installing smoke detectors in the home. [See Chapter 3 – “Prevent” – p. 29.]
Preparedness: In this phase people plan and train for emergencies, and perform practice exercises. At the local level, a Local Emergency Planning Committee (LEPC), Emergency Management Council, or similar government group comprised of government officials, the Office of Emergency Management Coordinator, representatives of the emergency services, and citizens design an emergency plan. Likewise, each family should develop their emergency or disaster plan. [See Chapter 4 – “ Prepare” – p. 52.]
Warning: This phase starts from the time of the detection of the threat and runs to the time of impact. For some disasters, such as hurricanes and winter storms, there is a long warning phase. For other disasters, this phase may be very short, for example, not more than about on average 13 minutes for some tornadoes. There may be no warning for other disasters, such as earthquakes or transportation accidents. [See “Alert Systems” in Chapter 4, p. 59 and 67.]
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What To Expect
Before
During Impact: The disaster strikes. The duration of the impact varies – minutes for an explosion, hours for a hurricane and even days for a major flood. During this phase, if they have not evacuated, individuals take action for their protection and survival.
After Response: During this phase responders are engaged in immediate emergency action. The major goals are to keep people safe and restore order out of the chaos caused by the disaster. The objectives are to save lives, protect property, and minimize psychological injury. Therefore, the tasks are rescuing, combating the threat (for example, extinguishing a fire), administering emergency medical care, protecting people, caring for basic needs, and providing emotional support. This phase may range from hours to days or even weeks depending on the nature and size of the disaster. The impact and response phases combined are also referred to as the emergency phase.
Recovery: This phase extends over the long term and may last years. The goal is to return to either the pre-disaster state or fashion a new and better way of life. People attend both to practical tasks such as repairing or replacing damaged property as well as to psychological tasks such as grieving for loved ones who died, coping with the loss of belongings, and healing from the trauma. For a few, it is a period to recover from physical injuries and/or receive treatment for mental disorders caused by the traumatic event. Some individuals may need to resolve deeper emotional issues that existed before the disaster and have became worse. If not addressed, 26
these emotional issues would likely impair their ability to cope with life’s responsibilities and experience life’s joys. There are specific things that you can do to help yourself and others during the emergency and recovery phases. [See Chapter 8 – “Help Yourself” – p. 14 and Chapter 9 – “Help Others” – p. 164.]
Do you know the sequence of an emergency response to a disaster?
Minutes to Hours: The local emergency services respond – police, fire, emergency medical services. As the incident grows in size, the Office of Emergency Management (OEM) responds to provide coordination and supply more resources. An incident command center is established near the scene. The incident commander directs the emergency response with the assistance of representatives from each of the emergency services. The National Incident Management System is the national standard method for directing an emergency operation. It provides a common technical language and emergency standard operating procedures (SOP) throughout the United States. As the need increases for additional emergency resources, the incident commander requests mutual aid responses from neighboring jurisdictions and finally from state agencies. As the emergency operation grows, an Emergency Operation Center (EOC) housed permanently in a specific location is placed into operation. The staff at the EOC arrange for resources needed by the incident command. There are local EOC’s for local emergency operations and state EOC’s for state level disasters.
State of Emergency: The local government declares a “state of emergency” because of the magnitude and duration 27
What To Expect
Response Sequence
of the disaster. The state government may also call a “state of emergency” because it is impacting several local government jurisdictions in the state. The governor may also activate the state’s National Guard units.
Federal Response: Once a state declares a “state of emergency,” the federal response is activated. Responding agencies would include the Office of Emergency Preparedness (OEP) and the Federal Emergency Management Agency (FEMA), both of which are divisions of the Department of Homeland Security. If the disaster requires a federal public health response, the Center for Disease Control and Prevention (CDC) is called in. Other government entities such as the military may also respond.
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3
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THINGS TO DO AFTER p. 37 Lessening the Impact of an Event (Secondary Prevention) p. 37 Lessening a Permanent State of Impairment (Tertiary Prevention) p. 38
DO YOU KNOW? In the Workplace p. 38 Mail and Hazardous Materials p. 39 Insurance p. 40 Flood Insurance p. 40 Evacuate vs. Shelter in Place p. 41 Decontamination vs. Privacy p. 43 Disaster Grants, Loans, and Funded Services p. 45 1 vs. 2 or More Collapsed Victims Rule p. 49 Collapsed or Seriously Injured Victim p. 49 TABLE Possible Protection for Terrorist Attacks p. 51 29
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THINGS TO DO BEFORE p. 31 Keeping an Event from Happening or Preventing Exposure to an Event (Primary Prevention) p. 31 Lessening the Impact of an Event (Secondary Prevention) p. 34 Lessening a Permanent State of Impairment (Tertiary Prevention) p. 36
PREVENT “Watch out for danger and chaos when they are still formless and prevent them before they happen.” Sun Tzu 505-473 B.C.
Knowledge is power. Now that you have read the first two chapters, and you know what to expect, use this as a springboard to learn the appropriate preventive actions. Why is prevention essential? Even a small preventive step such as wearing an automotive seatbelt can yield enormous benefit. An estimated 135,000 lives have been saved from 1975 through 2000 by this simple change in our behavior. There are multiple ways to prevent or mitigate. Public health uses the term “prevention.” Emergency management uses the term “mitigate,” that is, to lessen. There are three types of prevention: primary, secondary, and tertiary. Primary prevention is lessening or eliminating exposure to a danger. Secondary prevention is stopping the consequences (likely effects) after being exposed. Tertiary prevention is stopping the long-term effects once short-term effects develop. In medical terms, primary prevention limits exposure to what causes a disease. Secondary prevention wards off a disease after a person is exposed to a disease-causing agent or event. Tertiary prevention lessens the likelihood of disability developing after the onset of an illness or injury. Using the example of a terrorist attack, primary prevention begins with law enforcement investigation and surveillance to detect an imminent attack. Suspected terrorists are 30
apprehended before the attack is carried out. You can practice primary prevention by being vigilant and reporting suspicious activities. In secondary prevention, emergency personnel are ready and respond quickly to an attack. After experiencing an event, you can protect yourself and others from harm by taking certain actions. Decontaminating yourself after being contaminated with a hazardous material is an example of secondary prevention.
The first principle of prevention or mitigation is “always place safety first.” We have listed procedures to maintain your health and well-being, in addition to measures that might prevent or limit exposure to an accident, crisis and/or disaster. Although some of these actions provide secondary and tertiary prevention, you need to do them before the event, for example, purchasing insurance. Therefore, we have organized what you should do in a chronological sequence – “What to Do Before” and “What To After” – and within each group according to the type of prevention. Since this guide is not a first aid manual, we have not included any first aid procedures. Instead, we recommend that you take courses in first aid and CPR.
THINGS TO DO BEFORE Keeping an Event from Happening or Preventing Exposure to an Event (Primary Prevention) 31
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In tertiary prevention, government and relief agencies provide assistance and funds for recovery. If your arm is injured during a terrorist attack, you can practice tertiary prevention by engaging in physical therapy to prevent permanent disability.
Practice safety principles and procedures. For example: Be mindful of risks and potential dangers. Avoid storing flammable materials in your home. Be careful about storing non-flammable hazardous materials, for example household cleaning agents, in your home, especially if children or pets are present. Be extremely careful if you use candles. Smoke safely, if you must smoke. For example, refrain from smoking in bed. Keep all matches, lighters, and flammables out of the reach of children. Lock medications away from children. Drive safely and defensively. Drive only when alert and fully awake. Be especially careful when taking over-the-counter or prescription medications that might make you drowsy. Drive only if sober. Stop friends and/or family members from driving while intoxicated. Avoid talking on a cellular phone while driving. Practice bicycle safety, including wearing a helmet. Wear appropriate safety equipment when engaged in sports. Practice gun safety if you own and/or use firearms. Avoid walking alone after dark.
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Practice safety procedures on your job. [See “Do You Know?” – “In The Workplace” – in this chapter, p. 38.] Live a preventive and healthy lifestyle, and practice risk avoidance. Resist smoking tobacco. Avoid drug use. Make responsible decisions about drinking alcoholic beverages. Maintain a healthy diet.
Schedule time for sufficient rest and relaxation (R & R). Maintain good sleep habits. Get regular medical check-ups and screening tests as recommended. Be aware of the risks of driving, having unprotected sex, and using drugs; especially make certain your teenagers are aware. Be mindful of security, and practice security procedures. For example: Use your vigilance and intuition (“Listen to your gut.”) to detect potential threats. Report suspicious activity to police or other authorities such as security personnel. Safeguard your home with proper locks and lighting.
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Exercise regularly.
Protect your identity by refusing to give any identity information to unknown telephone callers. Practice health precautions when traveling, including recommended immunizations. Practice electronic protection and cyberspace security. For example: Protect your computer by using a surge protector. Use a backup battery for power outages. Use anti-virus and internet security software. Update virus definitions and security software frequently. Open e-mail attachments only from known senders. Resist forwarding e-mail that you have received from unknown sources. Download updates as soon as you are notified that they are ready. Avoid suspect internet sites. Be careful about what you download. Evacuate, if directed, during the warning phase of an impending disaster, for example, a flood, hurricane, or tsunami.
Lessening the Impact of an Event (Secondary Prevention) Prepare for disasters. [See Chapter 4 – “Prepare” – p. 52.] Wear seatbelts, use safety cribs for babies, and safety harnesses for children. Wear a medical information bracelet or neck chain to identify medical conditions, allergies, medications you 34
are taking that might cause dangerous drug interactions, and/or special needs, for example, blood type; ask your pharmacist for the names of the companies that sell these bracelets and chains. Install smoke detectors in your home, and change batteries at least twice per year (when you change your clocks for daylight savings time in April and back to standard time in October). Install a carbon monoxide detector in your home. Place an ABC fire extinguisher in your kitchen.
Strengthen your home against, natural disasters. If you are building a home, follow the building code, especially regarding special requirements for earthquakes, hurricanes, etc., in areas likely to be at risk for specific disasters. Consider using construction methods to protect your home from the potential damage of natural disasters even if they are not required by the building code. Bring an older home up to code. Practice electronic protection and cyberspace security. For example: Create an emergency recovery disk. Keep the original disks of your software and make back-up copies. 35
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Keep an emergency kit in your car or vehicle. [See – “Car or Vehicle Emergency Kit Checklist” – in Chapter 4, p. 66.]
Back-up your data files. Store back-up files in a secure place or places. Store second back-up files at a separate location. Use and periodically change passwords. Secure your financial data. Keep financial affairs up-to-date. Maintain essential financial records. Store financial records in a safe place, for example, a waterproof, fire resistant safe box with a lock, or bank safety deposit box. Protect your business. Use backup and data recovery software. Have a remote location to electronically store and replicate critical business data. Install or arrange for a backup telecommunication system. Arrange for an alternate place to conduct business.
Lessening a Permanent State of Impairment (Tertiary Prevention) Maintain an inventory, preferably with photographs of your valuable belongings. Get flood insurance if you live on a flood plain (your regular home insurance does not cover flood damage). [See “Do You Know?” – “Flood Insurance” – in this chapter, p. 40.] Make sure your homeowners insurance includes coverage for terrorism. 36
THINGS TO DO AFTER Lessening the Impact of an Event (Secondary Prevention) Take survival action. Evacuate, when necessary. * Rescue, if possible. Shelter in place, when appropriate. * * [See “Do You Know?” – “Evacuate vs. Shelter in Place” – in this chapter, p. 41.] Call 911.
Practice safety. Attend to medical emergencies. [See “Do You Know?” boxes – “1 vs. 2 or More Collapsed Victims Rule” and “Collapsed or Seriously Injured Victim” – in this chapter, p. 49.] Prevent further structural damage. Turn off utilities at main shut-offs, if not a risk to do so. Secure structure. For example, board up windows and entry doors. Attend to basic needs. Attend to mental health and social needs. Take essential financial records with you if you evacuate.
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Decontaminate, if necessary. [See “Do You Know?” – “Decontamination vs. Privacy” – in this chapter, p. 43.]
Lessening a Permanent State of Impairment (Tertiary Prevention) Inspect your residence for structural damage, if safe to do so. Document damage with written inventory and photographs. Get damage assessment from Red Cross and/or your insurance company. Make repairs and keep copies of paid bills. Seek professional help when necessary for: health and/or mental health care legal advice and/or representation Seek aid and grant funds from government and/or disaster relief agencies. [See “Do You Know?” – “Disaster Grants, Loans, and Funded Services” – in this chapter, p. 45.]
DO YOU KNOW? In The Workplace Do you know you have a right to a safe and healthful workplace? The Occupational Safety and Health Act of 1970 (OSH Act), P.L. 91-596, assures safe and healthful working conditions for working men and women throughout the United States. The Occupational Safety and Health Administration (OSHA) in the U.S. Department of Labor has the primary responsibility for administering the OSH Act. To file a complaint, report an emergency, or seek OSHA advice, assistance, or products, 38
visit the OSHA website: www.osha.gov or call: 1-800-321OSHA (6742) Adapted from OSHA 3165-09R
Mail And Hazardous Materials Do you know it is illegal and extremely dangerous to mail restricted or prohibited hazardous materials?
Although mailing of the most hazardous materials is prohibited, the statute allows the Postal Service to adopt rules prescribing preparation and packaging conditions under which certain hazardous materials may be mailed if they are not “outwardly of their own force dangerous or injurious to life, health, or property.” To learn more about it: 1. See Publication 52, Hazardous, Restricted, and Perishable Mail. 2. Contact your local post office. 3. Contact the Pricing and Classification Service Center (PCSC). New York PCSC 1250 Broadway 14th FL New York, NY 10095 212-613-8676 Adapted from United States Postal Service Notice 107 39
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With certain limited exceptions, the federal law Title 18 United States Code (18 USC) 1716 declares it is a crime to mail anything which may kill or injure persons or harm property. Persons violating the statute may be subject to fines, imprisonment, or other severe penalties.
Insurance Do you know how insurance might help? Having insurance does not prevent a disaster from happening. It does not prevent damage from occurring when a disaster strikes. However, insurance benefits can help you rebuild and rehabilitate by providing funds for loss and damage. Insurance may also provide funds for temporary shelter while your residence is being repaired. It is a way to foster recovery and lessen the possibility of the long-term effects of disaster. Therefore, insurance is a form of tertiary prevention. Homeowners should have homeowner insurance. Tenants should consider buying insurance to cover the loss of their personal property or renter insurance that may cover for theft, damage, loss of personal property, and liability for accidents. A landlord’s insurance covers the rental building; it does not protect the tenant and the tenant’s personal property. To learn more about it, call the National Consumers Insurance Helpline: 1-800-942-4242 or visit website: www.iii.org
Flood Insurance Do you know there is a national flood insurance program? Homeowner and renter insurance do not protect against damage and loss caused by floods, although it is estimated that 11 million homes in the United States are vulnerable to flooding. Even residences that are not located near bodies of water may be flooded or susceptible to landslides during extremely heavy rainfalls. Therefore, if you are a homeowner, renter, or business owner in a community that participates in 40
the National Flood Insurance Program (NFIP), created by Congress in 1968, you can obtain coverage through this program from agents that represent participating companies. Unlike federal disaster aid, which is only available if the president declares a federal disaster, flood insurance provides benefits even if a disaster is not declared. Special Flood Hazard Area
high flooding risk mortgage lender may require flood insurance
Non-Special Flood Hazard Areas
low or moderate flooding risk approximately 25% of floods occur in these areas
To learn more about it and determine what zone you are in, visit website: www.floodsmart.gov. To learn more about it and obtain an agent referral, call: 1-800-720-1090.
Evacuate vs. Shelter in Place Do you know when you should evacuate versus when you should shelter in place? Evacuation can take place before impact or after impact. During a warning phase prior to impact, it is best to evacuate areas that are likely to be the targets of certain events such as hurricanes, floods, or wildfires. You should take your emergency plan and evacuation kit with you [See Chapter 4 – “Prepare” – p. 52.] and proceed to a designated shelter or to lodging outside of the evacuation area. When there is a tornado warning, you may have an average of thirteen minutes to dash to a pre-designated shelter.
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After impact, there are some situations in which it is better to evacuate, and there are others in which it is better to shelter in place, that is, stay in the building that you were in when the emergency began. If the building was not directly involved at the time of impact, it is usually better to stay in place. If the building is structurally damaged or on fire, you should evacuate immediately. To help yourself to evacuate, think of the three “P’s” – pills, purse, and pets – so that you remember to take them with you. People often rush out without these, and then risk their lives attempting to go back and retrieve them. If a dirty bomb (Radioactive Dispersal Device) has been detonated outside while you are inside, you should remain inside and shelter in place so that you do not expose yourself to the radioactive material. If possible, seal off the windows and doors. Listen to emergency radio reports. If you are outside when the device is detonated, it is best to get away from the contaminated area as soon as possible. Move away from the area traveling against the wind. You can determine this direction by looking at the direction of the plume of smoke from the explosion, or which way a flag or other object is flowing in the wind, and go in the opposite direction. If you have become contaminated, you need to be decontaminated as soon as possible. [See the next “Do You Know?” – “Decontamination vs. Privacy” – p. 43.] Even if the bomb that has been detonated consisted of only conventional explosives, you should evacuate the area because there may be a secondary device (another bomb set to go off after the arrival of emergency responders in order to target them). You should not let your curiosity keep you at the scene. This is a time to remember “curiosity killed the cat.” In the case of a nuclear power plant disaster (accidental 42
or terrorist attack), authorities would alert the public by sounding sirens (within 10 mile radius), making announcements using vehicles with public address systems (within 20 mile radius), and broadcasting on the Emergency Broadcast System (within 50 mile radius). Once alerted, listen to radio or television emergency broadcasts to learn if you should evacuate or shelter in place. Evacuation would proceed along designated routes.
Shelter in Place Actions
Anywhere: when you shelter in place during a biological, chemical, nuclear, or radiological event: 1. Close and seal off windows and doors, if possible. 2. Turn off air-conditioning, fans, and heat. 3. Shut down air intake systems and block vents. If you have been directed to shelter in place, you should do so even if your children or other relatives are not with you. [See “Do You Know?” – “Reunion vs. Safety and Security” – in Chapter 5, p. 96.]
Decontamination vs. Privacy Do you know the best way to decontaminate while dealing with competing issues? When confronted with possible contamination by a biological, chemical, or radiological agent, you might be faced with the conflicting needs of self-preservation versus privacy. Privacy is not an insignificant matter. If you are uncertain 43
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At home: during a biological, chemical, nuclear or radiological event, you need to have a disaster supply kit that includes ample food and water for one week, and supplies to seal one room in order to create a safe-haven or safe-room.
whether you have actually become contaminated, you may be inclined to choose privacy over undergoing decontamination (Decon) because it would require you to completely disrobe. Unlike an approaching fire, you cannot see radioactivity. Hazardous chemicals are often in the form of clear, colorless, odorless gases. Biological agents are not visible to the unaided eye. Hazardous material enters your body if you ingest or inhale it, or if it becomes absorbed through your skin. It may also enter your system by injection, such as a puncture from sharp, contaminated debris. If there is any question that your skin might have become contaminated, it is better to undergo Decon, even though Decon would not be necessary if your skin was only “exposed” by your being in the vicinity of a hazardous material (HazMat). Although radioactive detection devices can measure whether your skin has become contaminated with radioactivity, such devices may not be readily available. If your skin has become contaminated, you should not eat, drink, place your bare hands near your mouth, rub your eyes, or touch others until you have been decontaminated. If you do not undergo Decon, you place others including children at risk. Even though undressing down to your underwear will remove 85% of the contaminating agent, you will still need to undress completely, wash thoroughly in a stream of water, and scrub the natural crevices of your body. Individuals have become ill by not undergoing this thorough procedure. Shampoo and soap are not necessary, but you may use them if they are available. Place all your clothing in a thick plastic bag, if possible, 44
You can wash under the loose fitting Decon gown. You may be wondering, “Wouldn’t I still be contaminated since the inside of the gown has touched my contaminated clothing?” The purpose of Decon is not to remove every particle of hazardous material but to reduce the amount of contamination below a safe level. We are exposed to hazardous materials all the time without being harmed. For example, we are surrounded by natural background radiation without damaging consequences. A sufficient amount of hazardous material will have been removed even when the gown is used. Nevertheless, you may change to a clean gown, if available, and if that would help you feel more at ease.
Disaster Grants, Loans, and Funded Services Do you know about the availability of disaster grants, loans and funded services?
From Disaster Relief Organizations Various disaster relief organizations provide shelter or funds for temporary housing. They may also provide emergency cash assistance or vouchers for purchasing essentials such as clothing and food. Local charities and faith-based organizations may provide services and financial support. Contact the local chapter of a disaster relief organization such as the American Red Cross or The Salvation Army, or 45
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and seal it. If you are concerned about being naked, you should know that emergency HazMat response units are often outfitted with a supply of disposable gowns that individuals can easily put on before they remove their clothing. These units are also usually equipped with Decon tents for privacy and with heaters to warm the water used for showering and the air inside the tent.
contact your local United Way. [See “Resource Directory – Disaster Relief Organizations” in Chapter 7, p. 132.]
From the Federal Government 1. Aid is only available when there is a presidentially declared disaster. 2. You need to fulfill the eligibility requirements. 3. You need to apply. Congress enacted the Robert T. Stafford Disaster Relief and Emergency Assistance Act, 42 U.S.C. §§ 5121-5206 in 1988 to establish support for state and local governments and their constituents when they are overwhelmed by disasters. This act describes the disaster declaration process, the types of federal financial assistance, and how to apply. There are three categories of financial assistance: 1. individual assistance – aid to individuals and households 2. public assistance – aid to public and certain private non profit organizations 3. hazard mitigation assistance – funds to institute methods that may reduce future disaster losses
Individual Assistance: Individuals and Households Program (IHP): This program provides funds and services for those whose property is damaged or destroyed, when their insurance does not cover these losses. There are funds for temporary housing and grants to repair disaster damage to your home. In unusual circumstances, there are limited funds to replace your disaster damaged home or construct a new home. There are grants for Other Needs Assistance 46
(ONA) such as medical, dental, funeral, personal property, transportation, moving and storage, and other expenses that might be approved.
Small Business Administration Disaster Loans: There are three types of federally subsidized loans from the Small Business Administration (SBA): 1. home disaster loans for renters and homeowners to repair damage to home or personal property, or replace damaged personal property 2. business physical disaster loans for business owners to repair or replace damaged property
Disaster Unemployment Assistance (DUA): This program provides unemployment benefits and re-employment services for victims who have become unemployed because of a presidentially declared disaster. In order to be eligible for DUA benefits, individuals must register with their state unemployment office. DUA funds are for individuals who are not covered by other unemployment benefits, such as farmers, migrant and seasonal workers, and the self-employed.
Legal Services: This program provides free legal assistance to low-income individuals through an agreement with the American Bar Association’s Young Lawyers Division. If you are the victim of a presidentially declared disaster, call: 1-800-621-FEMA (3362) or TTY 1-800-462-7585 to learn if you are eligible for any of these grants, loans or services, and to register.
Tax Considerations: You may qualify to deduct casual47
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3. economic injury disaster loans that provide funds to small businesses and small agricultural cooperatives to help them through the disaster recovery phase
ty loss from a declared disaster on your federal income tax return. If you are due a federal income tax refund, the Internal Revenue Service (IRS) can expedite your receiving the refund. Contact the IRS for Tax Questions to learn more about these tax considerations. Call: 1-800-829-1040
Crisis Counseling Assistance and Training Program (CCP): This program provides the funding for states to offer two types of short-term counseling services without charge to the recipients: 1. immediate – for the response to immediate mental health needs with screening and diagnostic services, counseling interventions, and outreach services such as public information and community networking 2. regular – to provide up to nine months of crisis counseling, community outreach, consultation, and education services Contact your state Office of Emergency Management (OEM) to learn more about these programs in your state, and what entity or entities administer them.
From State or Local Government Various states have grants, loans, and funded services that do not require a presidential disaster declaration. Contact your state OEM office. Local governments may allocate funds for temporary housing or other services through their emergency management offices or social service departments.
From Your Employer Inquire if your employer maintains an emergency fund 48
for employees who are victims of disaster.
1 vs. 2 or More Collapsed Victims Rule Do you know how to determine the presence of a toxic subtance and what to do?
One collapsed victim: approach, as long as there is no other danger, for example, a shooter or a collapsing structure, and assess the victim.
Two or more collapsed victims: If there is no obvious sign of trauma, a toxic substance is most likely the cause. Therefore, stay away and move out of the area immediately.
Collapsed or Seriously Injuried Victim Do you know what to do when a person has collapsed? Step 1. Assess for responsiveness and/or injury.
Do not move victim if there is any evident or possible injury to head, neck, or back unless absolutely necessary since moving the victim improperly may cause paralysis.
Tap or shake gently and shout, “Are you ok?”
Step 2: If Call 911 for Emergency Medical Services (EMS), especially if victim is unresponsive. Give following information:
location (rural – give address, if known, and/or 49
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Always call: 911.
Collapsed or Seriously Injuried Victim (continued) nearest crossroad, including estimated distance and direction from crossroad; suburban or urban – give address and nearest cross streets so that the EMS responders know which block you are in. Minutes, and even seconds, count in an emergency.)
telephone number you are calling from
what has happened (motor vehicle accident, fall, possible heart attack)
how many individuals need help
condition of victim or victims
what help is being given to victim or victims
Wait for instructions and/or permission to hang up.
Step 3: If victim is unresponsive check breathing and check pulse perform CPR (CardioPulmonary Resuscitation), if needed and if you are certified. Note: Two individuals can perform this strategy better than one, since the first person can do step 2 as the second person begins step 3. Try to recruit someone to help you.
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to counteract the effects of cyanide
to protect eyes, mouth, and nose, and to prevent the inhaling of biological and chemical agents while evacuating from contaminated building or area (20-30 minutes) used to counteract nerve agents; contains an atropine auto-injector and two PAM (pralidoxime chloride) auto-injectors
Cyanide Antidote
Escape Hood containing HEPA or high efficiency particle arresting filter $200 Mark I Kit
Recommendations By Experts
individuals should not stockpile because: –will be available for treatment –should only be prescribed, as necessary, for prevention or treatment –antibiotics can expire individuals should not obtain because: –difficult to administer –use requires trained medical personnel –would only counter the effects of cyanide if administered immediately worthwhile for those in high risk occupations
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Note: No special fitting and only minimal training is required, unlike a gas mask individuals should not obtain because: –available by prescription only –requires training to administer –can cause injury and adverse effects –may be supplied to emergency responders –medicine can expire Mask – Face to provide protection from inhaling biological agents; could buy disposable type and keep one at each disposable $2.75 may protect against radioactive dust but not location (home, work) but need at least N95 (blocks reusable $15-20 chemicals out 95% of particles 0.3 microns in size) Mask - Gas to protect eyes, mouth, and nose, and to prevent the having one is a personal choice, but: $250-300 plus filter inhaling of biological and chemical agents –needs to be fitted (canister) –requires special training –may need different canister for different agent –inconvenient to always have handy –exposure likely to have taken place already before mask can be donned –wearer may feel claustrophobic Potassium Iodide Tablets taken by mouth to protect the thyroid gland from only needed in 10 mile radius of nuclear power plant absorbing radioactive iodine (isotopes of iodine) Note: Authorities advise you to take if a significant Note: Potassium Iodide does not protect against dirty release of iodine isotopes from the power plant facilibomb radiation. ty has occurred.
to treat infectious disorders caused by biological agents such as anthrax, plague, etc.
Possible Protection for Terrorist Attacks Purpose
Antibiotic
Item/Cost
4
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PLANNING p. 54 Alert Systems p. 59 TRAINING p. 60 EXERCISE p. 61 FAMILY EMERCENCY PREPAREDNESS FORMS p. 63 Emergency Radio Station, Reunion Locations, and Contact Information p. 63 Medication/Health List p. 64 KIT CHECKLISTS p. 65 Disaster Supplies Kit p. 65 Car/Vehicle Kit p. 66 Evacuation Kit p. 66 First-aid Kit p. 66 ALERT SYSTEMS p. 67 Homeland Security Advisory System p. 67 Disease Outbreaks, Flash Floods and Floods, and Hurricanes p. 68 Thunderstorms and Lightning, Tornadoes, and Winter Storms p. 69
DO YOU KNOW? CERT p. 70 Exercises p. 71 National Pharmaceutical Stockpile p. 72 R.A.C.E. p. 73 Evacuating a Burning Building p. 74 Stop, Drop, and Roll p. 75 Types of Fire Extinguishers and Their Use p. 75 52
PREPARE “ . . . chance favors only the prepared mind.” Louis Pasteur 1854
“Luck is the residue of design.” Branch Rickey
Your preparation began in the first chapter when you learned about the statistical probabilities of various disasters, and continued through to the previous chapter when you focused on prevention and the mitigation phase of emergency management. It is essential that you have a prevention mindset. In the “best of all worlds,” primary prevention – keeping the event from happening or avoiding exposure to the event – is the ideal. But in the “real world” it is not possible to eliminate disasters or to always avoid them. Therefore, one needs to prepare for action in order to meet the challenges of disasters. Preparedness has three elements – planning, training, and exercise. Exercise is learning by doing and practicing what one has learned. For most people, training consists of learning by reading. Reading and internalizing our guide is part of this training. In addition, one can obtain other materials in hardcopy form or from various websites. For some, training may include taking courses to learn how to care for themselves and their families or to be citizen disaster volunteers. Training may also be available at one’s workplace or 53
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Be prepared! Now that you know what might happen and what to expect when a disaster strikes, you need to know how to respond and recover. You want to have luck on your side. Preparedness gives you an advantage.
school. For others, training will be part of their emergency services positions as police, firefighters, emergency medical technicians (EMTs) and paramedics, or emergency management (OEM) personnel. In this section, we present what you need to plan for at home, school, the workplace, and other locations. Disaster preparedness guides usually focus only on what to do at home. However, most people spend considerable time away from their homes working, driving or using public transportation, shopping, or engaging in recreational activity. In addition, you may be traveling or on vacation when a disaster strikes. Therefore, it is important for you to prepare a variety of contingency plans. How will you contact each other? If you are unable to contact each other, where will you meet?
PLANNING Home Make an emergency plan. Determine which disasters are more likely to happen in your community. Prepare for all disasters but especially those that are more likely to occur. Find out the emergency evacuation routes in your community. This is especially important for hurricanes and floods. Arrange for communication among your family members during an emergency. Arrange for a meeting place for your family:
in case of evacuation from your home (for example, a fire) – a safe place outside home 54
in case of evacuation from the area of your home or when your family is scattered and it is not possible to return to home – a place outside the area
Keep emergency telephone numbers near home phones. Have a least one corded telephone. (When there is a power outage cordless phones do not work.) List the radio stations that broadcast emergency bulletins in your area.
(For example: Since cordless phones do not work in a power outage, you should have at least one corded phone in your home. (Have you noticed that we said this twice? This is an example of redundancy.) If telephone cables are damaged, a cell phone will come in handy. What if your cell phone’s battery might be run down, and you may not be able to recharge it? It would help to have charged cell phone batteries as a backup. If the cell phone system goes down, use pagers to contact your loved ones. You can send messages on an alphanumeric pager system. If both cell phone and pager systems go down, use pay phones, if they are working. Always carry a phone card or spare change to be ready for this emergency. If the telephone system disruption is widespread, you may want to have walkie-talkies. If all communication technology is not working, you may need to send a runner to deliver a message. Always have a 55
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Have back-up, back-up, back-up, and more back-up! Redundancy is good.
pre-arranged meeting place to re-unite with your loved ones. Finally, amateur radio is the most dependable technology to use during a disaster. A Ham radio operator can transmit and receive messages by using only a handheld unit powered by a car battery. However, you need to pass an exam and become licensed to be a Ham radio operator.) Include your pet(s) in your emergency plan. Determine which agencies will shelter your pet(s). (The Red Cross does not allow pets in their shelters for health and safety reasons.) Keep a carrying case or cases handy for evacuating your small pets. (You may think you can just carry your pet. However, this may not always be possible.) Find out which agencies will rescue your pet from your home. (This would be necessary if you were not home when the disaster occurred, your pet is stranded, and you cannot get to your home, for example, during a flood.) Place the names and telephone numbers of agencies that shelter and/or rescue pets in your Family Emergency Preparedness Plan. Assemble: disaster supplies kit (for home use) car or vehicle kit (keep in vehicle) evacuation kit (to take with you if you must evacuate your home) first aid kit (for home use or evacuation)
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[See the two Family Emergency Preparedness Plan forms and the kit checklists in this chapter, p. 63.] (We recommend that you make enlarged copies of these and use them as part of your written emergency plan. Note: The Family Medication/Health Needs List includes “relationship” and “date of birth” for family members so you can give this form to the relief worker who is assisting you. This is necessary information for relief workers to have as they arrange to get replacement medications for you or a family member. You may also wish to include a few family photos and small mementos in your evacuation kit.)
Workplace Inquire about your employer’s emergency plan. Find out the following information from that plan: What procedures are there for the various emergencies that might occur?
What are the tasks recommended to be performed during an emergency? Who is assigned to what tasks or positions? What are the evacuation procedures? Consider joining the emergency committee. If you are self-employed, you should have an emergency plan for your business that includes: contingency plans if you are unable to operate your business in its usual location because of the disaster 57
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How will people be notified of an emergency?
backup systems for your records backup systems for communication Keep copies of your Family Emergency Preparedness Plan forms at work or carry them with you. Determine the locations of emergency exits. Keep a small disaster kit at your workplace. (The Red Cross has one for sale. There are small disaster kits available from private companies.)
School The United States Department of Education provides emergency planning information for schools on its website under the topic, “Safe Schools.” [See “ Resource Directory” in Chapter 7, p. 132.] Inquire, as a parent, about the emergency plan. Learn under what conditions the school would be evacuated. Learn under what conditions the school would be closed to anyone attempting to enter it and the students would be sheltered in place, that is, in the school. Find out where parents should report if a disaster were to occur. Attend planning or educational forum meetings on disaster preparedness. Middle and high school students should themselves inquire if their school has a peer program in which they can participate as peer helpers for disaster mitigation, preparedness, response, and recovery. 58
Other Locations Know where the exits are in public buildings. When traveling, inquire about hotel emergency procedures that are specific for the disasters that may be particular to that area. Check the CDC website for disease outbreak advisories before traveling overseas. [See “Alert Systems” below.] Note: The Joint Commission of Accreditation of Health Organizations (JACHO) requires that the hospitals that it accredits have a disaster plan and conduct two disaster drills per year. The plan must include procedures for emergencies within the hospital and disasters outside the hospital for which the hospital will provide services for victims.
Alert Systems “Fore-warned fore-armed”
There are various alert systems that issue advisories, watches, and warnings for natural disasters. In addition, the CDC has a notices and precautions system to advise travelers about disease outbreaks. These alert systems should be part of your emergency plan because they inform you about the various actions that you need to take for different conditions. The Homeland Security Advisory System was set up after 9/11 as a way to communicate information about terrorist threat conditions. It was designed primarily for law enforcement and emergency response agencies to take specific actions depending upon the probability of a terrorist attack. It has become part of our everyday lives. The public has often wondered what they should do when a specific 59
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Miguel De Cervantes circa 1605
level of threat is declared. The system includes information as to what individuals should do to protect themselves, their families, and their homes, in addition to what government agencies should be doing at each threat level. The threat level may not be the same throughout the United States. The Department of Homeland Security may determine different levels for particular geographical areas or kinds of industrial facilities. [See the advisory system tables in this chapter, p. 67]
TRAINING Useful for Any Location Read, understand, and know this entire pocket guide. If you skipped over any parts, go back and study them. Take a first aid course. Learn CPR. (Note: The American Red Cross offers a course that includes instruction both for first-aid and CPR.) Become a Community Emergency Response Team (CERT) member. [See “Do You Know?” – “CERT” – in this chapter, p. 70.] Teach your children how to call 911 and report an emergency. Learn the following procedures: R.A.C.E. – the actions you take when there is a fire how to evacuate a burning building stop, drop, and roll – used if you catch on fire PASS – how to use a fire extinguisher [See these procedures in the “Do You Know?” section in this chapter, p. 73.] 60
Home Educate yourself and your family about emergency procedures.
School and Workplace Participate in disaster training programs conducted by the organization.
EXERCISE “Practice is the best of all instructors.”
Emergency management uses the term “exercise” to refer to the act of performing or practicing a task in order to develop or improve specific skills. Individuals can train by participating in drills and other exercises. Exercises are also used to evaluate and test emergency plans. Although there are different types of exercises, drills are the type your family can engage in at home. For example, you and your family should practice evacuation drills from your home and evaluate how well you did. At work or school, you or a family member may be involved not only in drills but also other exercises. In addition, the Office of Domestic Preparedness of the Department of Homeland Security operates an exercise and evaluation program to maintain a state of readiness throughout the nation for potential terrorist attacks and other disasters. Therefore, as part of your preparation it is worthwhile to study the definitions of the different types of exercises. Then you will be a better informed citizen about national preparedness. For example, you will understand what is meant when you are told that there will be a “tabletop exercise” at your job. [See “Do You Know?” – “Exercises” – in this chapter, p. 71.]
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Publilius Syrus circa 42 B.C.
Home Rehearse escaping from your home as if there were a fire. Drive the evacuation routes in your area to become familiar with them. Practice taking refuge in your tornado shelter (for those living in tornado areas). Go through the procedures, such as R.A.C.E. or using a fire extinguisher, that you learned under training.
Workplace Be involved in the planning of disaster exercises. Participate in disaster exercises such as tabletop exercises and drills. Participate in evacuation drills.
School Be a parent representative involved in planning disaster exercises. As a parent you may wish to role-play in a disaster exercise at your child’s school if there is an opportunity to do so. (Note: Depending upon school policy, your consent may or may not be required for your child to participate in disaster exercises. We advise that any school should obtain your informed consent for your child to role-play in a disaster drill.)
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Family Emergency Preparedness Plan Emergency Radio Station, Reunion Locations, and Contact Information Emergency Alert System Radio Station: Call letters Frequency Reunion Locations: 1. Outside home: 2. Out of neighborhood: Directions to 2.
Evacuation route:
Emergency Telephone Numbers: 911 or Fire: Ambulance: Police: Physicians: Utilities:
Hospital: Local OEM: Poison Control: Pediatrician: Other: Telephone: Water: Pet Rescue:
Primary: Other: Electric: Gas: Pet Shelter:
Insurance: Family Contact Numbers: Name Cell Email School Phone
Friends and Nearest Relative Not Living at Home: Contact Type
Local
Nearest Relative
Name Address Address Cell Email Home Phone Work Phone
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Out of Area
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Work Phone
Family Emergency Preparedness Plan Medication/Health Needs List Name
Brand Name
Relationship Strength milligrams/dose
Generic Name
Date of Birth
Dosing
Special need (for example, wheelchair, medical apparatus): Name
Brand Name
Relationship Strength milligrams/dose
Generic Name
Date of Birth
Dosing
Special need (for example, wheelchair, medical apparatus): Name
Brand Name
Relationship Strength milligrams/dose
Generic Name
Special need (for example, wheelchair, medical apparatus):
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Date of Birth
Dosing
Resiliency: 10 Things to Do Family Emergency Preparedness Plan Batteries AAA AA C cell phone D 6 volt Cash Clothing Inclement weather gear Work gloves Documents Advance directives Bank account numbers and pass books Birth certificates * Credit card information Deed or lease* Immunization records Immigration and citizenship* Insurance policies* Licenses* Passport* Will* Flashlight Fire extinguisher (ABC type) Food (non-perishable – 3 day supply) Health Items Contact lens and eye supplies Extra eye glasses First aid kit Dentures and supplies Non-prescription medications Antacid Anti-diarrhea Laxative Pain reliever – aspirin and non-aspirin Personal hygiene Feminine hygiene Gel hand sanitizer
Mouthwash Soap Tissues Toilet paper Toothbrushes Toothpaste Prescription medications Insulin and needles Other Vitamins and supplements Infant care items Baby food Baby wipes Diapers Formula Matches in waterproof container Notebook and pen/pencil Other supplies Paper plates and cups, plastic utensils Plastic storage containers Pet Care Food Medication (if applicable) Other Supplies Radio (Battery operated with National Weather Service Station (NOAA)) Sanitation Antibacterial moist wipes Chlorine bleach Detergent Disinfectant Plastic garbage bags Plastic garbage container with lid Tools Can opener (non-electric) Knife (Army multi-gadget) Knife (regular) Pliers, screwdriver Wrench (to shut off gas and water) Water (1 gallon per person per day) – 3 day supply
*Originals of these items could be kept in a bank safety deposit box. If so,
make sure you have box # and key. You may keep copies with you.
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Disaster Supplies Kit Checklist
Car or Vehicle Kit Checklist Metal tracks Resiliency: 10 Things To Do Rock salt Family Emergency Preparedness Plan Tire chains Compass (for rural areas) Triangle reflectors Flashlight Tire inflator (aerosol) Flares Tire gauge Escape tool Tools Jumper cables Jack Maps Lug wrench – crossbar Evacuation route Pliers Other Screwdriver – phillips Moist wipes Screwdriver – straight blade Legal documents Shovel – regular Insurance card Shovel – snow (if applicable) License Wrench – adjustable Registration Wheel chucks - two Notebook and pen/pencil Windshield scraper and Paper towels brush (if applicable) Supplies to improve traction in ice Windshield washer fluid and snow Work gloves Cat litter
Evacuation Kit Checklist Resiliency: 10 Things To Do Infant Care Items * Antibacterial moist wipes Pet care Army multi-gadget knife Carry cases for small pets Batteries * Food Cash Medication (if applicable) Clothing (one change of clothes Other supplies and pair of shoes for each person) Notebook and pen/pencil Flashlight Personal Hygiene Supplies* Family Emergency Preparedness Plan Radio (battery operated) Important Documents * Sleeping bags Health Needs/Medication * Toys and Games Family Medication/Health Young child’s favorite stuffed Needs List animal or toy Prescription medications * See Disaster Supplies Kit Checklist
First Aid Kit Checklist First Aid Manual Emetic (to induce vomiting) Poison control telephone number Gloves (non-latex disposable) Adhesive tape (hypoallergienc) Instruments Alcohol (bottle and box of wipes) Scissors Antiseptic soap Tweezers Antiseptic spray Mouth-to-mouth resuscitation Bandages barrier (disposable) (Use Gauze pads only if CPR certified) Roll gauze Safety pins Triangular – 3 Thermometer Cotton balls (sterile) Water purification tables
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Homeland Security Advisory System Terrorist Attack Threat Level
SEVERE Risk
ORANGE
HIGH Risk
YELLOW
ELEVATED Significant Risk
BLUE
GUARDED General Risk
GREEN
LOW Risk
Increase or redirect personnel. Assign emergency responders and mobilize special teams. Monitor, redirect, or constrain transportation. Close public and government facilities not critical for essential operations.
Coordinate security efforts among agencies. Take further precautions at public events. Prepare to execute contingency procedures. Restrict access to a threatened facility.
Increase surveillance of critical locations. Coordinate emergency plans with nearby jurisdictions. Assess need for further refinement of protective measures. Implement contingency plans as necessary.
Check communications. Review and update emergency response procedures. Provide public with necessary information.
Refine and exercise protective measures. Train personnel. Assess regularly for vulnerabilities and work hard to mitigate them.
Avoid public gathering places. Follow official instructions. Contact employer about work status. Listen to radio and TV for advisories. Prepare to evacuate or shelter in place. Review preparedness measures. Avoid high profile or symbolic locations. Be cautious when traveling.
Be observant and report any suspicious activity. Contact neighboor about their plans and needs. Check school procedure for reuniting with children and emergency plan. Update household communication plan. Update disaster supplies kit. Review household emergency plan. Hold household meeting to discuss plan. Discuss plan with neighbors and friends, if you have special needs. Develop household emergency plan. Assemble disaster supplies kit.
Adapted from the Federal Emergency Management Agency’s Are You Ready? A Guide to Citizen Preparedness.
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RED
Protective Action Government Action Individual Action
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Direction of Severity and/or Likelihood of Occurrence
Warning Tropical Storm Warning Flash flooding or flooding has Tropical storm conditions are been reported or is imminent. expected in the specified area, Take necessary precautions at usually within 24 hours. once.
News Notice Watch Tropical Storm Watch There is a sporadic outbreak. Flash flooding or flooding is Tropical storm conditions are Traveler should avoid contact possible within watch area. Be possible in the specified area, alert. usually within 36 hours. with patients.
Outbreak Notice An infectious disease is confirmed for a specific region and not spreading. Get immunization – new or booster.
Hurricane Watch Hurricane conditions are possible in the specified area, usually within 36 hours. During watch, prepare to take action to protect your family and property in case a Hurricane Warning is issued.
Travel Health Precaution Urban and Small The infection is spreading over a Stream Advisory large area or between countries. Flooding of small streams, streets, and low-lying areas, such as railroad underpasses and urban storm drains is occurring.
NOAA National Weather Service www.noaa.gov
Hurricane
Hurricane Warning Hurricane conditions are expected, usually within 24 hours. Complete all storm preparations and evacuate if directed by local officials.
National Oceanographic and Atmospheric Administration (NOAA) National Weather Service
Flash Floods & Floods
Travel Health Warning Statement There is an expanding outbreak Follow-up information not yet under control. Postpone regarding flash flood/flood non-essential travel. If you do event. travel, take specific precautions.
Center for Disease Control and Prevention www.cdc.gov/travel
Disease Outbreak
Direction of Severity and/or Likelihood of Occurrence
Tornado Watch
Winter Storm Warning
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Below freezing temperatures are expected and may cause significant damage to plants, crops, or fruit trees. In areas unaccustomed to freezing temperatures, people who have homes without heat need to take added precautions.
Frost/Freeze Warning
Winter weather conditions are expected to cause significant inconveniences and may be hazardous. If caution is exercised, these situations should not become lifethreatening. The greatest hazard is often to motorists.
Winter Weather Advisory
Severe winter conditions, such as heavy snow and/or ice, are possible within the next day or two. Prepare now!
Winter Storm Watch
The infection is spreading over a Tornadoes are possible in your Severe winter conditions have large area or between countries. area. Remain alert for approaching begun or are about to begin in your storms. area. Stay indoors!
Severe Thunderstorm Watch
Blizzard Warning
Snow and strong winds combine to produce a blinding snow (near zero visibility), deep drifts, and lifethreatening wind chill. Seek refuge immediately!
Tornado Warning
A tornado has been sighted or indicated by weather radar. If tornado warning is issued for your area and the sky becomes threatening, move to your pre-designated place of safety.
National Weather Service
NOAA
Winter Storms
National Weather Service
NOAA
Tornadoes
Severe weather has been reported by spotters or indicated by radar. Imminent danger to life and property to those in path of the storm.
Severe Thunderstorm Warning
National Weather Service
NOAA
Thunderstorms & Lightning
Storms
DO YOU KNOW? CERT Do you know there are Community Emergency Response Teams (CERT) that you may join? As a member of a Community Emergency Response Team, you would work with your fellow citizen members to serve your local community when a disaster strikes. County or local emergency personnel – Emergency Management personnel, Emergency Medical Technicians and Paramedics, Firefighters, Police – train CERT members during a 20 hour course on disaster preparedness, basic disaster response, fire safety, the Incident Command System, damage assessment, disaster medical services, disaster psychology, light search and rescue, and team organization. The Community Emergency Response Teams are part of local Offices of Emergency Management. Team members would give critical support to first responders, such as firefighters and police, and would provide immediate assistance to disaster victims. To learn more about it, visit website: www.ready.gov CERT’s are a component of the Citizens Corps, a network of volunteer organizations that utilize the skills and abilities of the American people to prepare communities for the threats of terrorism, crime, and disasters. To learn more about Citizen Corps call: 1-800-WE-PREVENT (1-800-937-7383) or visit website: www.citizencorps.gov
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Exercises Do you know the different types of exercises?
Workshops: Participants are organized into small groups (break out sessions) and are assigned a task to complete such as designing a plan, discussing a scenario, solving a problem, or role-playing a specific procedure or skill. The individuals in the small groups may have assigned roles, such as group leader or recorder. After the breakout sessions, all the groups assemble together under the direction of a moderator to hear reports from the small groups and further discuss issues. Workshops can be used either for training or for producing a work product, for example, developing an emergency plan.
Tabletop exercises: Participants engage in discussing
Games: Participants are organized into two or more teams to competitively perform tasks and make decisions about an assumed situation. Games may use computer simulations that provide a more realistic depiction of an actual event. This exercise is used to perform “what-if” analysis, test out policies and procedures, and develop new plans.
Drills: Participants engage in an emergency scenario under supervision using actual equipment in an actual setting to practice and test the operation of a single agency or entity.
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or role-playing a simulated situation led by a moderator or exercise controller. Participants are key individuals such as senior staff and elected or appointed officials. The group can either focus on a scenario that is kept constant (basic tabletop) or on a scenario that is altered by the moderator (advanced tabletop).
Functional Exercises (FE): Participants from various agencies engage in a disaster scenario using actual equipment in an actual setting. The purpose of this exercise is to test and evaluate individual capabilities and interdependent functioning. It exercises plans, policies, procedures, and staff of Incident Command and Unified Command.
Full-Scale Exercises (FSE): Participants from a variety of prevention and response agencies mobilize over an extended period to a designated locale in response to a simulated attack. Operation TOPOFF is an FSE. It is a congressionally mandated, biennial, five-day national exercise directed by the Department of Homeland Security involving federal, state and local agencies to assess the response capability for a terrorist attack involving weapons of mass destruction. It may also involve international participation.
National Pharmaceutical Stockpile Do you know that the federal government has prepared for biochemical terrorism by stockpiling pharmaceuticals? The mission of the National Pharmaceutical Stockpile (NPS) program is to deliver needed medical supplies and medication to the site of a national emergency. This program maintains “12 Hour Push Packages” at various locations throughout the United States. These 12 Hour Push Packages contain a variety of medical supplies and equipment, medications, and vaccines. The inventory is periodically replenished with fresh supplies and medications. The program guarantees to provide these Push Packages by air or land within 12 hours after a request. Delivery of these stockpiles would augment state and local resources. 72
To learn more about it, visit the website: www.bt.cdc.gov/stockpile
R.A.C.E. Do you know what to do in case of a fire?
Rescue people in immediate danger. Alarm: If you are in a public building, activate the alarm, that is, pull the lever on the fire alarm box. If you are not near a fire alarm box, but you are in a building with a central telephone operator (for example, a hospital), call the operator and report the fire. If you are at home, call 911. Report the fire, give the location, and let the dispatcher know if anyone might be trapped.
Close all doors or Confine the fire. Exercise good judgment when deciding whether to
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attempt to Extinguish the fire. Evacuate immediately, if you decide not to attempt to extinguish the fire.
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Evacuating a Burning Building Do you know how to evacuate a room in a burning building? If you are in a hotel room or apartment and the door is closed, DO NOT OPEN IT. First, if there is a source of water in your room or apartment, wet a towel or cloth. Second, place your hand on the closed door. Is it hot?
No
Open the door. Do not use the elevator. Proceed to the nearest exit stairwell that is not blocked. If the hall is smoked filled, place the wet cloth over your mouth and nose, get low on the floor, and proceed to the exit stairwell. Exit the building.
Yes (Fire outside the door)
Do Not open the door. Place the wet cloth along bottom of the door to block the space against smoke. Call the fire department. Tell the dispatcher you are trapped. Give your location: If you are in a hotel, give name of hotel, address, the floor that you are on, and your room number. If you are in an apartment, give address, the floor you are on, and your apartment number.
Go to a window and wait. If there is a balcony, exit to the balcony, close the door behind you, and wait. Do not attempt to climb down.
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Stop, Drop, and Roll Do you know what to do if you catch on fire? Stop - Do not run. Drop to the ground. Roll on the ground to put the fire out. If someone is with you, they can help by throwing a blanket around you to smother the fire. Types of Fire Extinguishers and Their Use Do you know how to use a fire extinguisher? Extinguisher A
BC
ABC
Water
CO2
Dry Chemical
Ordinary paper, cloth, mattress
Yes
No
Yes
B
Flammable Liquids alcohol, grease, etc.
No
Yes
Yes
C
Electrical motors, equipment
No
Yes
Yes
Letter Code
Type
A
P ull the pin. A im the extinguisher at the base of the fire. S queeze the handle while holding the extinguisher upright.
S weep back and forth to extinguish the fire. Remember: Don’t let the fire get between you and the exit. After you use the extinguisher, place it on its side, or if you used it at work, give it to the maintenance department.
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Fire
5
LEARN HOW WE REACT
HOW WE REACT AS INDIVIDUALS p. 78 Before p. 78 During and Immediately After p. 79 Over Time p. 85 OUR FEELINGS p. 86 HOW INDIVIDUALS WITH SPECIAL NEEDS REACT p. 92 Children p. 92 Previously Traumatized p. 93 Seniors p. 93 People with Serious Mental Illness p. 93 HOW WE REACT AS A COMMUNITY p. 94
DO YOU KNOW? Reunion vs. Safety and Security p. 96 Traumatic Dreams p.98 TABLE Children’s Reactions to Disaster p. 100
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LEARN HOW WE REACT “It seemed the ground heaved, and I stopped and turned and saw this ungodly cloud with debris flying out of it rushing towards me. I knew I couldn’t outrun it, so I lied down flat on the ground, head first into the cloud.”
Who might react? Everyone! We all have strong emotional reactions to a disaster. The good news is that these reactions are natural and temporary in the majority of people. Although traumatic events are rather common, most people do not develop disorders after being exposed to a traumatic event. In the United States about 61% of men and 51% of women will experience at least one traumatic event during their lifetimes. Nevertheless, of those exposed to a traumatic event, only about an average of 14% to 24% develop chronic Posttraumatic Stress Disorder (PTSD). For reasons that are not fully understood, women are more likely, at a ratio of 2 to 1, to develop PTSD after being exposed to a traumatic event. In addition, the likelihood of developing PTSD depends on the nature and magnitude of the traumatic event, and one’s degree of exposure. For example, a study of the Oklahoma City bombing found that among those who directly experienced the explosion, 34% developed PTSD. By contrast, in the United States there is a lower probability of developing PTSD from natural disasters including fires (4.5%) compared to the probability of developing PTSD from any type of trauma (14.3%). In this chapter, we describe the natural reactions and emotions that you and others might experience in relation to 77
How We React
David LeClaire Port Authority Police Officer
disaster. We do this in four sections: 1) “How We React as Individuals,” 2) “Our Feelings,” 3) “How Individuals with Special Needs React,” and 4) “How We React as a Community.” The general individual reactions are divided into “Before,” “During and Immediately After,” and “Over Time.” The community reactions are divided into four phases – heroic, honeymoon, disillusionment, and reconstruction.
HOW WE REACT AS INDIVIDUALS Before Complacency: Between disasters we are usually complacent. We attend to our ordinary routines without any thoughts about the possibility of a disaster happening. Although 9/11 shocked Americans out of their complacency, human beings revert back over the course of time to being unmindful about the potential for disasters. Therefore, even the fears and energetic efforts generated by the trauma and loss of 9/11 might eventually peter out with the passage of time, the fading of memory, and the passing of those who experienced it first-hand. Anxiety: We become anxious when we are warned about an impending disaster. When we are barraged with repeated weather bulletins about a dangerous storm approaching our area, our anxiety intensifies. The hectic buying of bottled water and other supplies that quickly empties supermarket shelves is the result of normal anxiety during the warning phase of a disaster. If the storm proves not to be as terrible as predicted, some individuals may be complacent when there is a warning for the next potential storm. On the one hand, Homeland Security Advisory System alerts, which have announced elevated threat levels for a terrorist attack, have raised our anxiety periodically. On the 78
other hand, we have become jaded or cynical because constant alerts have never led to any calamity. Such alert systems can be like the “little boy who cried wolf.” Many individuals ignore fire alarms because they assume that most signals are tests or false alarms. You should always investigate if there might truly be a fire when any fire alarm sounds. It is best to think about the Homeland Security Advisory System as a reminder for us to be on the alert, rather than a means to inform us of an imminent attack. With this point of view, we may avoid both disregarding such alerts and becoming unduly anxious.
During and Immediately After Fight-Flight-Freeze: When faced with a threat to our
As human beings we retain the brain circuit that triggers this fight-flight-freeze behavior. This behavior occurs naturally and instinctively when we are threatened. It is merely a survival mechanism. Fighting is not necessarily heroic; fleeing may not be a sign of weakness. Courage and cowardice are judgments that we human beings make about these behaviors. When we are threatened, the best choice may be either to flee (evacuate the area before the hurricane hits or evacuate a burning building), to freeze (pretend to be dead while a mass killer is stalking the building on a killing spree or stay in an underground shelter until the tornado passes), or to fight 79
How We React
survival, we fight, flee, or freeze. These are inborn reactions that we share with other mammals. An animal of one species might turn on its attacker and fight. If it defeats its enemy, it goes on living. An animal of another species might flee and, thus, outrun its predator and survive. An animal of a third species might freeze in place and blend into its surroundings so that the deceived predator leaves to hunt elsewhere.
(attempt to put out a fire from a safe position or swim to safety when caught in flood waters). Although human beings have the unique advantage of possessing the instinct for all of these potential responses, our behavior can be guided by our higher cognitive functions. In other words, we have the instinctive reactions, yet we can also make decisions about what we do. But this can also backfire. We can acquire knowledge and learn values that might oppose, for better or worse, our automatic fight-flight-freeze reaction. Being told to stay put might counteract our instinct to flee because we have learned as part of our socialization process to obey rules. Preparedness training that is based on best practices and evidenced-based methods can teach us when we should override our learned behaviors and react with our “gut.” Our capacity to unlearn certain behaviors also makes it possible to reinforce other behaviors that are actually contrary to our instinct for survival. Emergency first responders are trained to rush toward the threat, placing themselves in harm’s way, in order to rescue victims and deal with the threat. Therefore, emergency training, whether for the general public or for emergency personnel, needs to include teaching about when to hold back versus when to rush in, and when to step back versus when to continue to advance.
Adrenalin Rush: An outpouring of stress-response chemicals, including noradrenalin in our brains and adrenalin in our bodies, is the biological basis for the fight or flight response. Therefore, when faced with a threat, we feel an “adrenalin rush” and experience a state of excitation. This process prepares us to go into action and helps us endure. Our pupils enlarge and heart rate increases. Our blood pressure rises. Our hearts pump our blood more efficiently. Blood 80
flow increases to our brains but decreases to our guts, skin and kidneys. Our muscles are stimulated. Our brains increase the production of endorphins, our natural painkillers. The adrenalin rush heightens our awareness, intensifies our focus, and causes us to “look sharp, feel sharp, and be sharp.” We are ready to go into action.
Action: Energized by adrenalin, we mobilize and do what has to be done to meet the challenge of the threat.
Panic: We usually do not panic during a disaster. It is a
Preparedness is another way to prevent panic. The antidote for panic is “to keep one’s head” and to analyze the situation. However, during a rapidly growing threat, one does not have the time to stop and slowly ponder what to do. Any decision needs to be swift. Preparation gives us the edge to perform well in the face of disaster and terrorism. With planning, training, and exercises, we can internalize a set of actions that we can carry out automatically and quickly when they are needed. For example, “Stop, Drop, Roll.” if you catch *This is a bar that is placed horizontally across the middle of an exit door and opens the door when pressure is aplied.
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myth that panic is a typical and widespread reaction to disasters. Nevertheless, we may panic – “lose our heads” – if we think we are trapped. When we become panicked, our judgment becomes impaired; we may attempt to secure safety recklessly. The panic of a few people can be contagious, and lead to pandemonium in a crowd. For example, incidents have occurred where people frantically fleeing a fire in a public building have packed up against exit doors and perished. One solution to prevent panic is to institute changes that reduce the chances of people becoming trapped, such as the use of panic bars* for exit doors and the enactment of building codes that require exit doors to open outward.
on fire. [See “Do You Know?” box – “Stop, Drop, and Roll” in Chapter 4, p. 75.] Acting in the Face of Conflicting Priorities: In the midst of a disaster or terrorist attack, we may be faced with conflicting priorities. The reality of the situation will not allow us to serve both needs. We must choose between one or the other. In some of these situations, we must act instantaneously in order to save lives; in others, we may have more time to think. Nevertheless, the consequences may be just as serious. In the aftermath of a disaster, if we were forced by circumstances to make such choices, we may accept that we did the best that we could, or we may become consumed with regret and a haunting, irrational guilt. Conflicting priorities include: Self-preservation versus self-sacrifice, that is, risking one’s life to save another Sacrificing one life in order to save another (This choice had to be made by at least one mother during the 2004 Asian tsunami. As the wave bore down on her she was holding a child in each arm. She let go of one and grabbed onto a tree in order to at least save the other. The child that she let go was swept away. Amazingly, both children survived.) Safety versus reuniting with loved ones, especially parents reuniting with their children [See “Do you Know?” – “Reunion vs. Safety and Security” – in this chapter, p. 96.] Self-preservation versus privacy with regard to disrobing in order to be decontaminated [See “Do You Know?” – “Decontamination vs. Privacy” – Chapter 3, p. 43.] 82
Self-interest versus concern for others
Decisions Related to Risk: During a disaster or act of terrorism, we may be faced with making risk related decisions. For example, is it safer to evacuate or shelter in place? What are my chances of becoming infected now that I have been told plague has been released? How do I protect my family and myself? Some individuals might question whether to trust authorities who are providing risk information. Others may be skeptical about any official information regarding risk. During emergency situations, there may not be adequate time to assess all the information. Therefore, it is very important that you learn what you should do in certain emergency situations to mitigate risk and be safe before the event occurs. position of leadership may take charge when faced with a life or death emergency. For example, a secretary saved lives on 9/11 because she determined the route to safety and insisted that the group she was with change their direction. They followed her and survived. Another example, also on 9/11, was of a businessman who led a group to safety while rescuing individuals he encountered along the way who were too numbed by emotional shock to move out of danger on their own. There have been times during battle when an ordinary soldier takes over his unit because its leaders have been critically wounded. The spontaneous leader may make the decision for a group about conflicting priorities.
Traumatic Stress: The adrenalin rush is sometimes a mixed blessing. It may help us survive the situation but then produces a powerful memory imprint that causes posttraumatic stress reactions. We replay the images – the sights, the 83
How We React
Spontaneous Leaders: Individuals who are not in any
sounds – in our minds over and over again. We feel upset. We can feel tense. We cannot fall or stay asleep. When we do fall asleep, we have distressing dreams. However, many people do recover from these initial reactions by making use of their natural abilities to deal with stress. For example, they do not avoid the reminders of the trauma. They talk anxiously about the terrifying experience with family and friends. They remain engaged. They look forward to the next day. They continue to function despite sometimes having difficulty concentrating or becoming irritable. After a brief time, the intensity of these reactions lessens, and the reactions disappear. This describes traumatic stress – a natural, short-term reaction to a catastrophic event.
Distress: Distress is a natural negative reaction to stressors of less magnitude, unlike traumatic stress, which is a natural reaction to a threat to life or limb of self or others. Stress is the non-specific response of our bodies to any demand, that is, to a stressor. Emotionally, short-term distress is experienced as anxiety. If we experience distress over a long-term, we feel helpless or become depressed. As stated above, we can worry and feel tense when we are alerted to an unfolding disaster. In addition, we feel distressed during a prolonged threat or after a disaster when we are concerned about how we will recover. The prolonged anthrax scare in the fall of 2001, during which many people worried about opening their mail and some sought prescriptions for Cipro, was not a direct threat to the population at large but still caused widespread distress. Individuals who have safely avoided a disaster can feel distress because of damage to their property, loss of their belongings, financial consequences, the frustration of dealing with the bureaucracies of disaster relief agencies, or even because of the difficulties of interact84
ing with strangers while residing at a shelter.
Over Time
Emotional Letdown: After the adrenalin rush ends and we cease our flurry of activity, we may feel an emotional letdown. While we were making last minute preparations before impact or responding immediately to a disaster, we were completely focused on crucial tasks. Afterwards, when the excitement settles down, we have time to reflect. We may feel sad and irritable when we are no longer engaged in action. Disaster workers may experience an emotional letdown after they have completed their tours of duty and have returned to their usual activities.
Dishonest Behavior: Unfortunately, a few people take
In the midst of chaos, some individuals loot or steal. Homes that have been evacuated may be burglarized. People may lie for profit or fame. Some individuals file fraudulent claims for disaster relief. Others might falsely claim that they were part of the rescue operation in order to be idolized as heroes.
Burn-out vs. Rejuvenation: After repeated responses to various disasters, emergency responders and disaster relief workers can develop burn-out. Likewise, as survivors of a dis85
How We React
advantage of a disaster to profit dishonestly. Some of them price gouge and engage in deceptive business practices. For example, they might overcharge for bottled water or blankets that people desperately need, pose as insurance facilitators for a fee, or jack up the cost for reconstruction. Therefore, “let the buyer beware.” As a disaster survivor, be careful and protect yourself from those who are trying to cheat you. You should report these individuals to the local authorities.
aster, we can experience burn-out when there is a long response phase or prolonged recovery phase. As ordinary citizens, we can feel burned out if the national threat level is continuously on a high alert. Individuals and organizations should take various steps regularly to rejuvenate themselves. For example, there should be sufficient periods of scheduled rest and relaxation for emergency workers during a prolonged operation. Survivors and their families and friends should engage in leisure activity and recreation.
Resiliency: Resiliency is the capacity of being resilient, which is from the Latin root resilire, “to jump back.” After experiencing horrendous chaos and destruction, we rebound and reconstruct our lives. Is resiliency inborn or something we learn, or does it result from an interaction of our genes and experience? Although science does not fully provide the answer, it is widely believed that preparing for disasters can foster resiliency. After a disaster, seeking out positive social support can help us “bounce back.”
OUR FEELINGS The following list of possible emotional responses is incomplete. This representative sampling is intended to show that there are a multitude of natural feelings that one can experience in response to trauma and loss. You most likely will not experience all these feelings. Likewise, you may not feel any specific combination of emotions. You may not feel your emotions in any particular sequence. Although we can have similar emotional reactions and share our happiness or grief, one’s feelings are a personal experience. Whatever you feel is genuine and natural. It is all right to feel anything that you feel. It is what you do based on your feelings that makes the difference. You may use specific feelings 86
to motivate yourself to accomplish good goals. As you go through a self-reflective process, you may determine that the thoughts that led to certain feelings were triggered by false assumptions or distorted thinking. For example, after awhile you may realize that your anger was misplaced, or there was no reason for you to feel guilty. After the passage of time, your feelings can become much less intense. It is a problem if you become frozen in one emotional state instead of moving back and forth among a number of feelings. For example, during the process of mourning, a person does not feel sad all the time. We may feel happy as we recall joyful memories of the person who has died. We may even laugh because we remember a ridiculous moment that we had shared with the deceased, but, at other times, we feel sad again. You may feel: angry (sometimes even rage) at: the individual(s) or organization who are responsible for a man-made disaster the terrorists or other individuals who intentionally caused the disaster
the government and/or disaster relief agencies because you think they are ineffective those who ignored your warning(s) yourself because you did not prepare sufficiently yourself because a decision you made was wrong 87
How We React
the individual(s) or organization you blame for causing the disaster but who are really not responsible
the deceased others who survived the disaster unharmed or avoided the disaster completely those who try to help you God anxious because: of the latest terrorist alert of a warning for an impending emergency of directly experiencing a disaster of your concern for the safety of your family and friends of your concern for your own safety you are uncertain about recovering of money problems caused by the disaster of your concern for the security of yourself and others of thinking that it might happen again of watching scenes of the disaster on TV apathetic because: you think, what is the use of trying? it has happened before (for example, this is the third flood in five years) the event is prolonged but no longer frightening demoralized because:
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you now doubt certain previously held views about life – the world is good, the world is meaningful, and you are worthy you question, why do bad things happen to good people? despair when everything appears hopeless you feel you are all alone disgust upon: seeing the remains of the dead smelling foul odors seeing the accumulation of waste elated because: you have triumphed you feel intense self-satisfaction frightened because: your life is being threatened the lives of others are being threatened
you think you will become violent after experiencing violence frustrated when: your personal recovery is slow reconstruction is slow 89
How We React
you think it will happen again, and you will become a victim just like a relative, friend or even a stranger with whom you identify
obstacles are difficult to overcome happy because: you have counted your blessings you are grateful for what you still have grief : for the death of a family member or friend shared with your community or nation because of mass casualties guilty because: you survived, but a family member, friend or co- worker did not you think you failed to do enough, especially something that you think would have saved someone’s life or kept someone from being injured you think you did something that caused someone to die or to be physically injured you think you did or said something that wounded someone emotionally you are angry helpless when: you do not have the means to help yourself you do not have the means to help others physical pain from an injury interferes with your activity or function you feel that no matter what you do, nothing will change 90
horror upon: suddenly being threatened by death witnessing others being suddenly threatened by death seeing others die seeing the remains of the dead hearing what happened watching scenes of the disaster on TV or seeing photographs in the print media joy because: you have survived the “worst of it” others have survived the “worst of it” your home has survived the immediate impact of the disaster numb (without emotion) because: you are reacting to the chaos you are reacting to the sudden death and devastation powerless because: you think you have no control over your life there are forces of nature you cannot control
you and your loved ones survived you and your loved ones have endured over the long term you realize it could have been worse 91
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relief because:
sad because: you have lost your belongings, family mementos, and photographs you have lost your home and/or job your life has drastically changed you think things will never be the same shame: for feeling vulnerable for feeling that you did not master the situation because you feel you should not have looked at the dead or the people who were dying
HOW INDIVIDUALS WITH SPECIAL NEEDS REACT In addition to the reactions and emotions mentioned above, individuals in groups with special needs may exhibit the following:
Children There are two major ways that children react to a disaster: Change in behavior: A child changes from his typical and usual behavior. For example, an outgoing child becomes passive and quiet. Regression: A child reverts to past behavior of an earlier stage of development. For example, a child who had ceased sucking her thumb or bed-wetting reverts to sucking her thumb or bed-wetting. [See table – “Reactions of Children to Disaster” – in this chapter, p. 100.] 92
Previously Traumatized Is trauma exposure immunizing – does it make us better able to deal with the next trauma when it comes; or is it sensitizing – does it “wear us down” so that we have even more difficulty dealing with the next trauma? Scientific data demonstrates that exposure to a trauma is sensitizing. Therefore, individuals who have experienced previous traumas – childhood abuse, combat, rape – even if they did not develop a disorder at the time of exposure, are at risk for developing disorders if they experience subsequent traumatic events. An individual with PTSD in remission is at risk of relapsing when exposed to a current traumatic event. A person suffering with active PTSD may experience a worsening of his symptoms when exposed to another traumatic event. However, we don’t know whether getting treatment for a disorder does, in fact, increase your resilience. Many professionals believe that it does, but the research hasn’t been conducted yet.
In a disaster, seniors have many basic needs and reactions similar to other populations. They also have strengths and weaknesses that make them both more resilient and yet more vulnerable. Their life experience has afforded them the gift of survival, and with that comes better coping abilities. However, frailty also comes with age, and this can bring on fatigue and despair.
People with Serious Mental Illness Many people with serious mental illnesses may be resilient in the face of a disaster despite their illnesses; they 93
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Seniors
may rise to the occasion and perform well or even heroically. Nevertheless, the stress of the situation may aggravate a preexisting disorder. Schizophrenia may cause a person to become emotionless and lose self-motivation. Therefore, a person with this disorder may appear disinterested and be unable to pitch in. In addition, people with delusions may interpret the disaster or terrorist attack in a way that incorporates it into their delusions. [See Chapter 6 – “Decide When to Get Help” – p. 101.]
HOW WE REACT AS A COMMUNITY The predominant post-disaster emotional states and behaviors exhibited by groups or communities post-disaster can be divided into four phases. The time frames can vary, depending on whether there is a single event of relatively short duration, a single event of relatively short duration followed by a persistent threat, or a prolonged event. In addition, the duration of the phases can vary, depending on the severity of the disaster. These phases are: Heroic Time Frame: from the moment of impact to the period immediately thereafter Emotional State: excited and energized (strong and direct) Behavior: heroic actions to save oneself, rescue others, and protect property Social Resources: emergency workers, family, neighbors
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Honeymoon Time Frame: from about one week to three or four months after the disaster Emotional State: positive feeling of shared experience with others who have lived through the catastrophe and survived the threat even though their loved ones may have died and/or their possessions may have been lost hope that they will receive substantial help Behavior: joint efforts to recover the remains of the dead joint efforts to clean up the wreckage and recover the belongings that can be salvaged Social Resources: influx of official agencies that promise help Disillusionment Time Frame: from about two months to one or two years Emotional State: anger, bitterness, disappointment, frustration, resentment
Behavior: survivors individually concentrate on building their own lives and solving their own problems Social Resources:
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feeling of loss, including the loss of “shared community”
various agencies fail to meet the survivors’s expectations outside agencies leave some local groups do not continue Reconstruction Time Frame: several years Emotional State: positive: reaffirmation of self and community negative: intense emotional problems, especially if there is a delay in rebuilding Behavior: survivors take responsibility for solving problems and rebuilding focus on construction, new plans and programs Social Resources: individuals and groups who have a long term investment in the community
DO YOU KNOW? Reunion vs. Safety and Security Do you know that one of the most powerful urges that you will experience at the time of a disaster is the need to be with your loved ones? As family members and friends pursue their daily activities, they go their separate ways. When disaster strikes, we may often not be with those we love. Children may be at school. Adults may be at work. Retired seniors may be enjoying a hobby at a local center. A telephone company marketing campaign that encouraged people to “reach out and touch 96
Although the human bond is extremely strong, it may not always be advisable or possible to act on the instinct to reunite with loved ones. The need for safety and security may oppose the desire to be with family and friends. Individuals who attempt to reunite, no matter what the cost, may risk their own lives and the lives of others. Individuals who insist on being with their loved ones may interfere with emergency workers, jeopardize the effectiveness of an emergency response, and add to the chaos and the risks. In the midst of a disaster, the distraught behavior of a family member may be distressing for a survivor to witness. Studies have demonstrated that children are more likely to suffer adverse reactions if they observe their parents exhibiting uncontrolled behavior. Although it is usually best for loved ones to unite as soon as possible during a disaster, especially parents and children, it may be necessary and, in some situations, better to tolerate the separation. [See “You” under the “ABC’s of Caring for Children” in Chapter 9, p. 179.] Remaining separated is a real test of a person’s self-control. A recent study on human behavior in response to a 97
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someone” was very successful because that is exactly what people want to do under ordinary circumstances. In the midst of chaos and terror, the urge to reach out is greatly multiplied. When threatened with danger or imminent death, we yearn to be with those we love. When we fear for the lives of our loved ones, we crave to connect with them and be convinced that they are safe. During the chaos and destruction of a disaster or terrorist attack, our instinct is to seek those we love. As disaster mental health responders, we have witnessed, time and again, this powerful force of human attachment. In the aftermath of 9/11, people frantically sought to find their missing relatives and friends.
hypothetical dirty bomb terrorist scenario discovered that 40% of the people surveyed would not shelter in place as long as needed (either not staying at all or leaving prematurely), even though sheltering in place is the recommended method of protection for a dirty bomb. The two main reasons these individuals would not shelter in place were: to care for their children (33%) and to care for another relative (25%). Of the people who said they would leave, 14% would stay if they could communicate with those they care about, and 12% would stay if they knew that the people they care about were being well taken care of even though they could not communicate with them. It is important that you have several ways of contacting family members and friends during a disaster. It is essential that you have a pre-arranged place to meet when you cannot connect by telephone. [See Chapter 4 – “Prepare” – p. 52.] Preparedness also includes knowing the school’s emergency plan to evacuate and to shelter your child. Likewise, you should know the emergency plan of the nursing home, rehabilitation center, or assisted living facility where your senior relative resides. This is essential pre-disaster information because you need to be assured that your child or other relative will be protected during a disaster, if you cannot get to them immediately.
Traumatic Dreams Do you know that your dreams can help you to heal after psychic trauma? Dreams are our thoughts while we are sleeping. They are a natural process of our brains and minds. We always dream when we sleep, but some people seldom recall their dreams and others frequently do. 98
There are various theories about the purpose of dreams. Two major opposing views of dreams are that they are either a random neurobiological process that deletes the “nonsense” files or fragments of memory that accumulate in our brains, or that they are a method to process information. The former view would be analogous to our deleting all the empty files with names like ~WRL3769.tmp that accumulate in our computers. In this view dreams have no meaning. The authors subscribe to the latter theory that dreams are a way to process information. Thus, we may resolve unconscious conflicts, process new information, problem-solve, or even produce creative ideas while we dream. However, the meaning of a dream is usually disguised. By analyzing the images in our dreams, we can attempt to understand their meaning and application to our life situation.
How We React
After experiencing a traumatic event, it is natural to experience distressing dreams about the trauma. Over time these distressing dreams either just stop happening, or their tone and images change from being frightening to becoming neutral or even pleasant. In this case, the person has processed the trauma. Nevertheless, some individuals will have persistent nightmares. Various images related to the trauma will replay night after night like a continuous loop. In this case, the person is not processing the trauma, but is frozen in a traumatic reaction. If distressing dreams haunt you after being exposed to a traumatic event, talk with a mental health professional.
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100
Pre-School
expressions of fear crying (whimpering, screaming, calling for help) excessive clinging trembling and fearful immobility running toward adults running aimlessly changed behaviors confusion eating problems marked sensitivity to loud noises sadness sleep disturbances –insomnia (awakens during the night) –nightmares –unable to sleep alone or in the dark speech difficulties weather fears–high winds, lightning, rain regressive behaviors asking to be dressed or fed bed-wetting excessive whining or clinging fear of darkness, animals, being left alone, strangers, crowds loss of bladder and/or bowel control
Up to Five-Years-Old
emotion anger irritability sadness behavior aggression (frequent fights with other children) disobedience excessive clinging refusal to socialize body headaches nausea upset stomach regressive behaviors bed-wetting irrational fears, for example, about buildings collapsing sleep disturbances –insomnia –nightmares –unable to sleep alone or in the dark weather fears school related behaviors behavior problems distractibility loss of concentration loss of interest poor academic performance
6 through 11-Years-Old
Latency
Children’s Reactions to Disaster
emotion anger irritability sadness behavior aggression antisocial behavior (stealing, vandalism) confusion isolation sleep disturbances –insomnia –increased sleep –nightmares use of alcohol and/or drugs withdrawal body headaches stomach pains school related behaviors absenteeism disruptive behavior poor academic performance
12 through 17 Years-Old
Preadolescent and Adolescent
DECIDE WHEN TO GET HELP
YOU NEED HELP WHEN p. 103 Basic Needs p. 103 Financial Needs p. 103 Health Needs p. 103 Legal Matters p. 114 Social Needs p. 114 Spiritual Needs p. 115 Your Pets and/or Farm Animals p. 115 Your Property p. 116 Your Small Business p. 116 GROUPS WITH SPECIAL NEEDS p. 116 Children p. 117 Physically Disabled p. 117 Seniors p. 117 People with Serious Mental Illness p. 118
DO YOU KNOW? Grief vs. Depression p. 118 Psychological Reactions to Nuclear, Radiological, and Chemical Events p. 120 SYMPTOM CHECKLISTS p. 121 Acute Stress Disorder p. 122 Major Depressive Episode p. 123 Posttraumatic Stress Disorder p. 124 Suicide Risk p. 125
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6
DECIDE WHEN TO GET HELP “No man is wise enough by himself.” Titus Maccius Plautus 254-184 B.C.
“By speaking of our misfortunes we often relieve them.” Pierre Corneille 1640
How do you know when to seek help? Making this decision is critical to your physical and mental health. This chapter highlights the various reasons that you might need help after a disaster. Later, in Chapter 7, we will present the many resources which can provide you with help. In addition, in Chapter 8, we will present ways to help yourself. Now you should address the question – Why would someone need help after a disaster? In this chapter, we list numerous things that might happen to you and that would require you to seek help. These misfortunes, symptoms, and illnesses could also happen to family, friends, or neighbors. So everywhere “you” appears, you may substitute “someone.” We also outline the situations that require help regarding property, pets or farm animals, and/or small businesses. We address how to recognize when you or others may need to seek help. We do not include every medical emergency – only those that are likely to be caused by or occur in the midst of a disaster or terrorist attack. Do not hesitate to seek help. It takes courage to ask for help. Doing so does not mean you are weak. It is always better to ask for assistance, even if it later turns out that you do not need it. Therefore, when in doubt, always ask for help. 102
Basic Needs During response phase, you have: no water no food no blanket and/or clothing no shelter During recovery phase, you have: no food no clothing no place to live
Financial Needs During response phase, you have: no cash During recovery phase, you have: no money for rent no funds to rebuild no job because of the disaster no property insurance no health insurance
Health Needs Your medication and/or healthcare devices for preexisting conditions were lost or destroyed.
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When To Get Help
YOU NEED HELP WHEN
You have new health care needs, and you do not have access to care. You have health equipment that operates on house current and there is no electricity. You do not have health insurance or you had health insurance with your job but lost your job because of the disaster. You develop certain symptoms or disorders, such as:
General Medical Heart and Circulatory System You may be having a heart attack (myocardial infarction (MI): You should seek help:
immediately, if you or others experience any of the symptoms of a heart attack:
men –typical first symptom: severe aching, discomfort, pressure or pain in chest, arm, or below breastbone (sternum) –pain or discomfort radiating to the arm, back, jaw, or neck –apprehension and restlessness –dizziness, nausea, sweating, or vomiting –shortness of breath –extreme weakness –irregular or rapid heartbeat
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women –upper back pressure –chest pain or pressure similar to men –shortness of breath –pressure in lower chest that could be mistaken for stomach problem –unexplained fatigue
Receiving treatment within one to two hours of the onset of the symptoms can be life-saving and prevent further heart damage. You may be having a stroke (cerebrovascular accident (CVA)): You should seek help:
immediately, if you or others experience any of the symptoms of a stroke (the type of symptoms depend on where the “accident” occurs in the blood vessels that supply the brain)
The symptoms occur suddenly and include:
temporary blindness in one or both eyes
confusion
slurred speech
spinning sensation
double vision
weakness and/or numbness of arms and/or legs
falling without loss of consciousness 105
When To Get Help
inability to express oneself (nonsense talking or cannot use correct words)
loss of consciousness
Infections You may get an infection:
from a disease outbreak
from drinking contaminated water or eating spoiled food after a disaster
from a wound, especially if it is not treated
from mold while living in a contaminated house that was damaged by flood waters
during a bioterrorism attack
You should get help immediately, if you are exposed to one of these conditions and develop any of the following:
fever
upper respiratory symptoms (cough, congestion, mucus)
gastrointestinal symptoms (diarrhea, nausea, vomiting, abdominal pain)
painfulness, redness, swelling of a healing wound
headaches with or without stiff neck
skin rash
[See the tables in the Appendix – “Disease Outbreaks: Causative Agent, Transmission, Symptoms and Things to Do” – p. 188 and “Things to Know for Bioterrorism” – p. 190.] 106
You may be injured during a disaster because of:
electric shock
fires
flying debris (including broken glass)
a fall
being swept up in rushing flood waters
the impact of an explosion
being in a collapsing structure
exposure to freezing temperatures (frostbite)
lightning
radiation burns
You should seek help:
immediately for any serious injury, including burn injuries
immediately for bleeding
immediately for frostbite
as soon as practicable for any injury other than a minor scrape
Lung Disorder You may develop difficulties with your lungs because of:
smoke from a fire
fumes containing hazardous materials from an industrial or transportation disaster 107
When To Get Help
Injuries
breathing in dust from a collapsed building, especially if it contained asbestos
toxins released during a terrorist attack
infection
You should seek help:
immediately, if you have been contaminated by hazardous materials
if you develop persistent lung symptoms (cough with or without phlegm, chest pain)
Metabolic Disturbance You may develop a metabolic disturbance due to:
dehydration (water reduction because of, for example, not drinking enough in hot weather, sweating, diarrhea, or vomiting)
heat exhaustion
heat stroke
hypothermia
You should seek help, for:
heat stroke immediately – it is a medical emergency
hypothermia immediately
Poisoning You may be poisoned by:
carbon monoxide, for example, from using a gas powered generator which is not vented properly
hazardous materials – chemical or radiological – 108
a chemical agent released during a terrorist attack
You should seek help:
immediately for signs of carbon monoxide poisoning: headache, nausea, vomiting, weakness [Note: evacuate an enclosed area immediately if you and/or others suddenly develop these symptoms. If you stay, you will first become unconscious and then die.]
immediately, if you are exposed to a suspected or actual hazardous material
[See table – “Things to Know for Chemical Terrorism” – in the Appendix, p. 189.] Pre-existing Conditions You may experience a worsening of a pre-existing condition because: your usual health care services are not available your medication has been destroyed or lost you are not able to keep to your diet, for example, if you are diabetic the stress of the experience worsens your condition
Mental Health You should seek professional help: immediately, if you or others experience:
suicidal thoughts, urges, plans, or behavior
violent thoughts or behavior 109
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released during a disaster, especially industrial or transportation disasters
an urge to hurt yourself
confusion
delusions and/or hallucinations
as soon as possible if, after a few weeks have passed, you or others experience:
angry outbursts
numbness, emotional distance or estrangement
impaired functioning – at work, with family or friends, or caring for yourself
inability to concentrate
intense, persistent anxiety
memory impairment
overwhelming stress
persistent sadness
persistent insomnia
primarily one dominant emotional state without the ability to switch between pleasant and unpleasant feelings
You should seek professional help for the following disorders: Adjustment Disorder: This is a disorder that develops within three months of experiencing a stressful life event and lasts no longer than six months after the stressor has ended. The person experiences anxiety, depressed mood, and/or conduct disturbances. In addition, the individual either exhibits impaired functioning or distress that is greater than what 110
Delirium: This is a disorder in which an individual experiences a sudden alteration in his awareness of his surroundings, with an inability to focus or maintain his attention. He is disoriented, that is, he does not know the date and time and where he is; he may also experience hallucinations. Delirium could be caused by a general medical condition such as an infection, poisoning, or head injury. The poisoning could occur when a person becomes contaminated with a hazardous material. Dementia: The key feature of this disorder is deterioration of previously acquired intellectual ability. This primarily involves memory impairment but also includes being unable to recognize things, carry out learned behaviors, understand and use language, and/or perform the mental tasks of planning, organizing, sequencing, and abstract thinking. This syndrome can be the result of a direct injury to the head during a disaster. Dissociative disorder: This is a disorder in which a person’s mind cannot integrate the mental functions of consciousness, memory, identity, or perception of the environment. For example, an individual would: 1. be unable to recall the traumatic event 2. experience being outside her body observing herself, and/or 111
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would usually be experienced relative to the life event. Exposure to a traumatic event can also trigger this disorder in addition to stressful life events, such as business failure, divorce, a general medical condition, or loss of employment.
3. feel detached from her environment as if her surroundings were not real Generalized anxiety disorder: This is a disorder in which a person experiences persistent worry, anxiety, and tension. The person worries repeatedly about a number of things despite reassurances. People who know him may say, “Even if there was nothing to worry about, he would find something to worry about.” Major Depressive Episode: Major depressive episodes can be triggered when a person experiences adverse life events or traumatic events such as disasters and terrorist attacks. Depression may be triggered by the helplessness that people may experience, particularly during a prolonged hardship, such as a difficult and lengthy recovery phase. Traumatic loss, such as the traumatic death of a loved one during a disaster or terrorist attack, may also lead to a major depressive episode. [See “Do you know?” “Grief vs. Depression” - p. 118 and “Symptom Checklists” - “Major Depressive Episode” - p. 123 in this chapter.] Panic Disorder: In this disorder the individual experiences recurrent panic attacks consisting of dread or intense fear that quickly builds in intensity and is accompanied by bodily symptoms, such as racing heart, sweating, shortness of breath, nausea and upset stomach, dizziness, or faintness. The individual usually fears that she might be having a heart attack, losing control, or “going crazy.” After she experiences the first attack, she worries that she 112
Phobia: In this disorder a person has an intense, irrational fear of things or situations, with a desire to avoid those things or situations. The individual either avoids them or endures them with dread. Posttraumatic stress disorders: There are two types:
Acute stress disorder [See – “Acute Stress Disorder” – in this chapter, p. 122.]
Posttraumatic stress disorder: This is a disorder in which characteristic symptoms develop after a person is exposed to a traumatic event. During the exposure, the person reacts with intense fear, horror, and/or helplessness. The key feature of the disorder is that a person reacts as if the original threat is still present. He re-experiences the trauma in thoughts, feelings, dreams, and bodily symptoms. He avoids cues of the trauma and feels numb. He has symptoms of increased arousal, such as the inability to fall or stay asleep. [See – “Posttraumatic Stress Disorder – in this chapter, p. 124.]
Psychoactive substance use disorders: An individual with one of these disorders either abuses or is dependent on psychoactive substances. These include alcohol, nicotine, illegal drugs such as cocaine, hallucinogens, heroin and marihuana, and those prescription medications that are potentially 113
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might have another and may alter her usual behavior, for example, she may avoid places which she previously visited but that she now associates with the attack.
addictive. Individuals with these disorders may use substances to numb their unpleasant emotions, cope with trauma and loss, and/or tolerate physical pain. Psychosis: This a syndrome in which an individual is unable to distinguish what is real. Delusions and /or hallucinations are usually present. For a very few individuals, extreme traumatic stress can precipitate psychotic reactions. (These are not all the types of mental disorders, but only those that would likely be associated with disaster and terrorism. Delirium and psychosis always require immediate professional attention.)
Legal Matters Your legal documents were destroyed. You need legal assistance applying for special disaster funds. You think you might have a liability claim. There are pre-disaster legal matters that can affect you as a beneficiary. For example: A loved one without a will died in the disaster. Your partner died in the disaster but your marriage was not recognized or you were not married.
Social Needs During response phase, you: are separated from loved ones and need to be reunited have no social support 114
have no social support need new social activities because old ones are lost, for example, a facility – senior center, local club – was destroyed, or you had to relocate away from the immediate area need to share your experiences with others
Spiritual Needs Before the disaster, you: want to use your spirituality or religion to prepare for a disaster are not a spiritual or religious person, but at this time of terrorism you wish to seek such a path Anytime after a disaster, you: are a spiritual or religious person invoking your beliefs at a time of tragedy, trauma, and loss are a spiritual or religious person, but now are having doubts because of a traumatic event were not a spiritual or religious person previously until a trauma or loss triggered your need for faith
Your Pets or Farm Animals During response phase, your pets or farm animals: need to be rescued are physically injured are contaminated with hazardous material need uncontaminated water and/or food 115
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During recovery phase, you:
need shelter During recovery phase, your pets: demonstrate changed behavior such as fear, irritability or not eating well
Your Property During response phase, you need: authorization and an official escort to enter your damaged residence to claim your belongings During recovery phase, you need: a damage assessment to have your home cleared of debris and cleaned to have mold removed after water damage to repair or rebuild your damaged home to deal with the fact that your property has been condemned because of damage to apply for disaster relief funds or grants
Your Small Business During response or recovery phase, you need: same as “Your Property” [See above.] to set up a temporary location of operation to recover electronic business records
GROUPS WITH SPECIAL NEEDS In addition to the needs, symptoms, and disorders listed above, you should also seek help when the specific conditions occur for each group listed below. 116
You should consult a mental health professional when your child has persistent reactions to a disaster, her reactions intensify, or they interfere with her functioning. In addition, even if your school-aged child has natural reactions, if these cause problems for her or others at school, you should seek guidance and work cooperatively with her teachers and other school professionals. [See table – “Children’s Reactions to Disaster” – in Chapter 5, p. 100.]
Physically Disabled People with disabilities should have additional help when they: need assistance to evacuate require repair or replacement of medical equipment need special transportation are faced with the destruction of their usual accessible environment
Seniors Seniors should have additional help when they: need assistance to evacuate have developed dehydration are suffering from heat stroke in hot weather, especially if no air conditioning is available due to a power outage experience worsening of a pre-existing general medical condition are faced with a disruption of medical and/or social services 117
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Children
People with Serious Mental Illness People with serious mental illness should have additional help when they: experience a worsening of their pre-existing mental illness are faced with a disruption of access to care
“DO YOU KNOW?” Grief vs. Depression Do you know that there are certain warning symptoms that grief is turning into depression? Grieving is a natural process. As individuals, we mourn when a loved one dies. As a community, we mourn collectively when there is a public death. As a nation, we mourned those killed in the terrorist attack in Oklahoma City on April 21, 1995, and the September 11, 2001 terrorist attacks on New York City and Washington, DC. When a loved one dies, we may take solace in religion, shared rituals, and spirituality. When we grieve, we may seek out a relative or friend for sympathy, talk to clergy, attend a self-help bereavement support group, or even participate in counseling with a mental health professional. There are times, however, when a grieving person may need treatment, including possible medication. One of these times is when grief develops into clinical depression. Why is this difference important? It is important because clinical depression can lead to suicide. If suicidal thoughts are present, one should always see a mental health professional. How does one distinguish between grief and depres118
Three main factors distinguish grief from depression: 1) intensity, 2) variability, and 3) content. 1. Grieving individuals usually continue to function, even if there are times when they have to force themselves to do so. By contrast, clinical depression is gererally severe enough to interfere with the ability to function to some degree. 2. One’s mood usually switches back and forth during the process of mourning. There are intense times of crying, loneliness, and emptiness interwoven with times when one is enjoying being with family and friends, or engaging in some interest. During an episode of depression, an individual’s mood is usually persistently sad almost all day, everyday. 3. Although guilt and hallucinations can be part of both grief and clinical depression, their contents are usually different. While grieving, a person may feel survivor guilt: “Why didn’t I die instead?” or the guilt of not having done enough: “It’s my fault. I should have tried harder to stop him from going.” In depression, guilt usually takes the form of: “I did something terribly wrong” and is often accompanied by feel119
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sion? For a variety of reasons, the length of the grieving process is not a good indicator. One person’s period of grief might be shorter or longer than another’s. The length of the mourning period can be culturally determined. How a person died may alter the duration of one’s grief. For example, grief due to traumatic loss – death from a traumatic event such as a disaster – may last longer because the person died suddenly, unexpectedly, violently, and perhaps early in life. Some individuals may never stop grieving even though they have continued to function and have gone on with their lives.
ings of worthlessness: “I’m no good. I never do anything right.” One can hallucinate during grief, that is, sense something that is not present or not really happening, and not be “crazy.” This usually consists of seeing the deceased, especially when one is alone at night. In certain cultures, the norm is seeing and communicating with the deceased. In depression, the hallucination is usually a voice criticizing the person. The voice may also tell a depressed individual to kill herself.
Psychological Reactions to Nuclear, Radiological, and Chemical Events Do you know that most symptoms in reaction to a nuclear, radiological, or chemical event are psychological? Here is what is known from three events:
Three Mile Island Nuclear Reactor Accident: On March 28, 1979, damage occurred to the casing around the radioactive core of reactor 2 (TMI-2) at the Three Mile Island nuclear power plant near Harrisburg, Pennsylvania. Although the incident occurred essentially over sixteen hours, public alarm continued for several days because of misinformation and misunderstanding. Two days after the accident, the Nuclear Regulatory Commission recommended that the governor of Pennsylvania proceed with an evacuation of the area. Although there had been a gaseous radioactive release from the plant, levels of measured radioactivity in the area were low. The maximum radiation dose to any individual in the surrounding area would have been less than the amount naturally received annually from background radiation. Nevertheless, subsequent studies demonstrated that people living within 20 miles of the TMI experienced sub120
Goiania, Brazil Radiological Event: On September 13, 1987, an abandoned radiotherapy device was broken open. The radiation contaminated 249 people resulting in 4 deaths. However, 113,000 people who were not contaminated feared that they were and sought medical care. Some of these fainted and experienced diarrhea and vomiting.
Terrorism in Tokyo Subway: On March 20, 1995, the Aum Shinrikyo cult released sarin, a nerve gas, in the Toyko subway. The attack killed twelve and resulted in 5,500 seeking emergency care. Of those seeking help, 3,454 did not have any signs of contamination but were anxious and highly aroused.
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stantial immediate psychological distress. An estimated 52% of those living within 20 miles fled the area during the accident. 26% of those studied were demoralized within one month of the accident. Even five months after the incident, the public in the area continued to mistrust authorities regarding the safety of nuclear power.
ACCUTE STRESS DISORDER If during or after experiencing or witnessing a traumatic event, any of the following symptoms occurred: I felt numb and detached or felt no emotional response. I felt dazed and did not know where I was. I felt like things happening around me were strange, mechanical, or not real. I felt that I was out of my body observing myself or like I was in a dream. I was unable to recall what happened. and after experiencing or witnessing the traumatic event, any of the following symptoms have occurred: I persistently reexperience the trauma through: 1) recurrent images, thoughts, or nightmares 2) a sense of re-living the trauma, and/or 3) distress when exposed to reminders of the trauma. I avoid feelings, thoughts, conversations, activities, places, and/or people that remind me of the trauma. I am very anxious or show symptoms of increased arousal, for example, I have difficulty sleeping, feel irritable, am unable to concentrate, am looking around thinking something will happen, easily jump or startle, and/or feel restless. I find it difficult to function with others, at work, or in other important areas of my life, or I cannot do some necessary task like seek disaster relief assistance. SEE A PROFESSIONAL FOR AN EVALUATION 122
I feel sad or empty almost all day every day, or others tell me that I am depressed. My interest in all or almost all activities is markedly diminished, or I no longer feel any pleasure in all or almost all activities for most of the day for nearly every day, or others tell me that I have lost interest. I have had a significant weight loss without dieting or a weight gain (a loss or gain of more than 5% of body weight in a month), or I have experienced a decrease or increase in my appetite every day. I am unable to sleep, or I sleep more than usual every day. I am agitated (pace back and forth) or sit without much movement every day. I feel tired or have no energy nearly every day. I feel worthless or have excessive guilt nearly every day. I have difficulty thinking or concentrating, or I have difficulty making decisions nearly every day. One of the following: I have recurrent thoughts of death. I have recurrent thoughts about killing myself although I do not have a specific plan. I have tried to kill myself. I have a specific plan to kill myself. I find it difficult to function with others, at work, or in other important areas of my life. SEE A PROFESSIONAL FOR AN EVALUATION 123
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MAJOR DEPRESSIVE EPISODE If any of the following symptoms have occurred:
POSTTRAUMATIC STRESS DISORDER If any of the following symptoms have occurred and persisted after the traumatic event that you have experienced or witnessed: I am on the alert that something threatening might happen. I am unable to remember some of the important parts of the event. I easily jump or startle. I experience distressing recurrent and intrusive recollections of the event. I feel detached or estranged from others. I experience intense emotional distress when I am reminded of the event. I feel irritable and/or have angry outbursts. I find myself acting or feeling as if the event is happening again. I have difficulty concentrating. I have difficulty falling asleep and/or staying asleep. I have physical reactions like a rapid heartbeat, sweating, and/or trembling when I am reminded of the event. I have recurrent distressing dreams about the event. I make an effort to avoid or do avoid activities, places, and/or people that arouse recollections of the event.
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I make an effort to avoid or do avoid thinking, feeling, and/or talking about the event. I think that somehow my future will be cut short. My interest or participation in previously enjoyed activities has greatly diminished. My loving feelings for others are restricted. SEE A PROFESSIONAL FOR AN EVALUATION Adapted by permission of William H. Simon, George E. Ehrlich and Arnold Sadwin from Napoli, JC “Mind/Body, Body/Mind, Mind/Brain, and Post-Traumatic Stress Disorder” in Conquering Chronic Pain: An Integrative Approach to Treating Post-Traumatic Pain.
SUICIDE RISK Do you know how to recognize if someone is at risk for committing suicide? Talking about suicide (It is a myth that people who talk about suicide don’t do it.) Anxiety and anguish Hopeless, helpless, and worthless Loss of interest Focused on death Signs of preparing for death suddenly happier or calmer because the person has decided suicide is the solution placing one’s affairs in order giving belongings away contacting friends and relatives in a manner that is not typical for person ASSIST PERSON TO GET PROFESSIONAL HELP 125
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POSTTRAUMATIC STRESS DISORDER (continued)
7
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TYPES OF RESOURCES p. 128 Professional vs. Non-professional Help p. 128 Resources for Adults p. 129 Resources for Youth p. 129 RESOURCE DIRECTORY p. 130 Advocacy and Self-Help p. 130 Aviation Disasters p. 131 Children p. 131 Crime p. 132 Disaster Relief Organizations p. 132 Environment and Food p. 133 Health, Mental Health, and Public Health p. 133 Homeland Security p. 134 International p. 134 Military p. 134 Professional p. 135 State and Territory Offices of Emergency Management (OEM) p. 136 Travel Safety p. 136 Weather p. 136
DO YOU KNOW? Families of September 11 p. 137 National Air Disaster Alliance/Foundation p. 137 National Organization for Victims Assistance (NOVA) p. 138 National Self-Help Clearinghouse p. 139 National Voluntary Organizations Active in Disaster (NVOAD) p. 139 Peer Helpers p. 140 126
SEEK HELP “Ask, and it shall be given you; seek, and you shall find; knock, and it shall be opened unto you.”
Making the right choice about seeking help is a complex and sometimes risky process. Before seeking help from others, you need to consider how it might benefit you and how it might harm you. For example, in some situations confiding in a supervisor about your personal matters may adversely affect your job. Your internal conflicts and concerns may be viewed as potentially damaging to your judgment and job performance. Your decision to self-disclose any traumainduced emotional effects should be guided by your knowledge of your employer’s management style, your relationship, and your past history. Regarding the decision to seek support from others, some people assume that talking to a trusted co-worker who has also been involved in the disaster will probably cause distress or traumatize that person. This is not necessarily true. Don’t let this belief keep you from reaching out to that trusted co-worker. In some cases, it might be beneficial to both of you to share your experience of the disaster. You need to weigh the risks and benefits to both you and the other person. Determining the risks is not always easy, but you can use your knowledge of a co-worker’s previous behavior, and his vulnerabilities and strengths to guide you in your decision. It may also be helpful to get an outside perspective by talking with someone other than a trauma survivor. Don’t assume someone who did not go through the disaster will 127
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New Testament, Matthew 7:7
not be able to understand. Sharing ideas and feelings, and getting objective feedback can be comforting and lead to new insights. Family members, professionals, colleagues, coworkers, members of the clergy, and trusted friends are potential supportive resources you may consider. The following is a list of possible individuals and organizations that you may turn to after experiencing a crisis or disaster. Once you realize you need help, you will also need to decide whether to seek a professional or a non-professional resource or agency.
TYPES OF RESOURCES Professional vs. Non-Professional Help Why turn to professionals for help? Professionals should: be better trained and skilled to deliver supportive services be knowledgeable about diagnosing acute and extreme reactions that require ongoing treatment be objective, neutral, and unlikely to be swayed by a relationship with the survivor be able to deliver empathic support Why turn to non-professionals (relative, friend or coworker) for help? Non-professionals may: have personal knowledge of and a shared background with the survivor, which can be helpful in knowing how to offer the best support be more sympathetic to someone they know have been through the same crisis or trauma, and thus may more effectively assist the survivor to adopt a better functioning state of mind (It helps to share experiences.) 128
have a more positive influence over the survivor because of a deeper relationship At Your Workplace: trained crisis and/or grief counselors on staff employee assistance programs (EAP) crisis and/or grief counselors who are members of health insurance networks human resources department staff members trained peer helpers trusted co-workers who were affected by the crisis trusted co-workers who were not involved in the crisis medical department for employees In Your Community: community based crisis counselors on the scene clergy who are trained in crisis and grief counseling local mental health professionals county or state crisis hotlines, usually in departments of mental health services local or county assault/rape crime agencies, usually referred through county prosecutor’s office local psychotherapists specializing in stress disorders and grief local emergency rooms self-help clearinghouses (self-help theme support groups such as loss of family members, sexual/physical abuse, and widow/widower) your physician
Resources for Youth At Your School: 129
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Resources for Adults
guidance counselors student assistance counselors trained peer helpers school nurses school-based support teams (psychologists, social workers, and mental health workers) school-based resource officers (police) In Your Community: trusted family members or friends self-help groups self-help books youth-oriented hotlines The Compassionate Friends [See listing in the “Resource Directory” p. 131.] Rainbows groups (bereavement programs) [See listing in the “Resource Directory” below.]
RESOURCE DIRECTORY This resource guide is intended to support readers with a wide variety of needs and issues. It is the result of careful screening of numerous agencies and organizations. It is divided by category for your convenience. Addresses and phone numbers are included when available.
Advocacy and Self-Help These sites offer disaster-related and subject-related self-help groups, emotional and physical support, legal support, prevention services, assistance, and educational information. Many offer links to other sites. Anxiety Disorders Association of American (ADAA) / 8730 Georgia Avenue, Suite 600, Silver Spring, MD 20910; (240) 485-1001. www.adaa.org Families of September 11 [See p. 137.] National Association of Students Against Violence Everywhere (SAVE) / 322 Chapanoke Road, Suite 110, Raleigh, NC 27603; (919) 661-7800. Toll-free: (866) 343-SAVE (7283). www.nationalsave.org National Self-Help Clearinghouse [See p. 139.] 130
Rainbows / 2100 Golf Road #370, Rolling Meadows, IL 60008; (847) 952-1770. Toll-free: (800) 266-3206; E-mail:
[email protected] SAVE (Suicide Awareness Voices of Education) / Hotline: (800) 273-8255. www.save.org The Compassionate Friends, Inc. / P. O. Box 3696 Oak Brook, IL 60522; (630) 990-0010, FAX: (630) 990-0246. Toll-free: (877)-969-0010. www.compassionatefriends.org Trauma Anonymous / www.bein.com/trauma These resources offer financial, emotional. and legal support to air crash victims and their families. Some offer links to other sites. Aircraft Casualty Emotional Support Services (ACCESS) / 1594 York Avenue, PMB 22 New York, NY 10028. Toll-free: (877) 227-6435. www.accesshelp.org National Air Disaster Alliance/Foundation (NADA/F) [See p. 137.]
Children These sites offer valuable resources for disaster preparedness and prevention, coping with terrorism, and child traumatic stress. They provide information about long term effects of radiation and bio-terrorism, disease outbreak prevention, and responses. Some have information regarding child care services during disasters and crises. Others focus on educational and social needs of children. Their publications provide guidelines and suggestions for parents, schools, and agencies to help children cope with disasters and crises. Many offer links to other sites. American Academy of Child and Adolescent Psychiatry (AACAP) / 3615 Wisconsin Ave., N.W., Washington, DC 20016; (202) 966-7300. www.aacap.org American Academy of Pediatrics / 141 Northwest Point Boulevard, Elk Grove Village, IL 60007; (847) 434-4000. www.aap.org Apple Care Foundation / 41 West 57th Street, 4th Floor, New York, NY 10019; (212) 688-0635. www.applecarefoundation.org Church of the Brethren, Emergency Response/Service Ministries / 601 Main Street, P.O. Box 188, New Windsor, MD 21776. Toll-free: (800) 451-4407, ext. 7. 131
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Aviation Disasters
National Association of School Psychologists (NASP) / 4340 East West Highway, Suite 402, Bethesda, MD 20814; (301) 657-0270. www.nasponline.org National Child Traumatic Stress Network (NCTSN) / www.nctsnet.org National Children’s Advocacy Center (NCAC) / Center, 210 Pratt Avenue, Huntsville, AL 35801; (256) 533-KIDS (5437). www.nationalcac.org Purdue University / West Lafayette, IN 47907 USA; (765) 4944600. Toll free: (888) EXT-INFO (398-4636). www.ces.purdue.edu/terrorism US Department of Education (DOE) / 400 Maryland Avenue, SW, Washington, DC 20202. Toll-free: (800) USA-LEARN (872-5327). www.ed.gov
Crime The following sources offer legal, practical, physical, and emotional support and treatment for crime victims. Many offer links to other sites. Federal Bureau of Investigation (FBI) / J. Edgar Hoover Building, 935 Pennsylvania Ave, NW, Room 7350, Washington, DC 20535; (202) 324-3000. www.fbi.gov National Organization for Victims Assistance (NOVA) / [See p. 138.] The Office for Victims of Crime (OVC) / U.S. Department of Justice, 810 Seventh Street NW, Eighth Floor, Washington, DC 20531; (202) 307-5983. www.ovc.gov The Office on Violence Against Women (OVW) / 810 7th Street, NW, Washington, DC 20531; (202) 307-6026. www.ojp.usdoj.gov/vawo The Victims’ Assistance Legal Organization (VALOR) / 8180 Greensboro Drive, Suite 1070, McLean, VA 22102-3823; (703) 748-0811. www.valor-national.org
Disaster Relief Organizations The following sources offer medical, financial, safety, and physical relief to victims of all disasters. Many offer links to other sites. American Red Cross / www.redcross.org National Voluntary Organizations Active in Disaster (NVOAD) / [See p. 139.] The Salvation Army / 615 Slaters Lane, P.O. Box 269, 132
Alexandria, VA 22313. www.salvationarmyusa.org
The following sources offer environmentally related and food related educational information on food safety, poison control procedures, and emergency response services. They provide bio-hazard alerts and resource quality regulation. They also offer local, state, and national center listings, networks, hotlines, and resources. Many offer links to other sites. American Association of Poison Control Centers (AAPCC) / 3201 New Mexico Avenue, Suite 330, Washington, DC 20016; (202) 362-7217. Poison help hotline: Toll-free: 800-222-1222. www.aapcc.org Department of Agriculture / www.foodsafety.gov Department of Environmental Protection (EPA) / Ariel Rios Building, 1200 Pennsylvania Avenue, N.W., Washington, DC 20460; (202) 272-0167. www.epa.gov The Food Safety and Inspection Service (FSIS) / USDA Meat and Poultry Hotline: (888) MP Hotline (674-6854). www.fsis.usda.gov
Health, Mental Health, and Public Health These sites contain valuable resources on public health threats, homeland security, counter-terrorism, emergency preparedness, and responses to environmentally related diseases, bio-terrorism, and outbreaks. Some include valuable information on and emergency responses to hazardous materials incidents. Programs for the homeless, mental health information, hotlines, substance abuse prevention, and treatment information programs, and referral sources are included in some of these sites. Many offer links to other sites. Academic Centers for Public Health Preparedness / www.asph.org/acphp Department of Health and Human Services (DHHS) / 200 Independence Avenue, S.W., Washington, DC 20201; (202) 619-0257. Toll-free: (877) 696-6775. www.hhs.gov Centers for Disease Control and Prevention (CDC) / 600 Clifton Rd, Atlanta, GA 30333; (404) 639-3311. Toll-free: (800) 311-3435. www.cdc.gov Indian Health Service / The Reyes Building, 801 Thompson Avenue, Ste. 400, Rockville, MD 20852; (301) 443-1083. www.ihs.gov 133
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Environment and Food
National Institute of Mental Health / Office of Communications, 6001 Executive Boulevard, Room 8184, MSC 9663, Bethesda, MD 20892; (301) 443-4513. Toll-free: (866) 615-6464. Anxiety Hotline: Toll-free: (888) 826-9438. www.nimh.nih.gov Substance Abuse and Mental Health Services Administration (SAMHSA) / 1 Choke Cherry Road Room 8-1065 Rockville MD 20857; (240) 276-2000. www.samhsa.gov US Public Health Service / www.usphs.gov
Homeland Security The Homeland Security Act of 2002 established the Department of Homeland Security (DHS) to prevent terrorist attacks within the United States; reduce the vulnerability of the United States to terrorism, natural disasters, and other emergencies; and minimize the damage and assist in the recovery from terrorist attacks, natural disasters, and other emergencies. The main office and two of divisions are below. Department of Homeland Security (DHS) / Washington, DC 20528; (202) 282-8000. www.dhs.gov Federal Emergency Management Agency (FEMA) / 500 C Street, SW Washington, DC 20472; (202) 566-1600. Toll-free: (800) 621-FEMA (3362). www.fema.gov Readiness / (202) 282-8000. www.ready.gov
International The following sources offer international relief and disaster recovery, emergency management, reconstructive efforts, and disease prevention initiatives outside the USA. Some offer links to other sites. The Disaster Preparedness and Emergency Response Association (DERA) / P.O. Box 797, Longmont, CO 80502, www.disasters.org Office of Foreign Disaster Assistance (OFDA) / Information Center, U.S. Agency for International Development, Ronald Reagan Building, Washington, DC 20523; (202) 712-4810. www.usaid.gov/index.html World Health Organization (WHO) / Regional Office for the Americas, 525, 23rd Street, N.W., Washington, DC 20037; (202) 974-3000, Fax: (202) 974-3663. E-mail:
[email protected] www.who.int/en
Military These sources offer national security, military, and anti-ter134
rorism services as well as protection and support to military personnel and veterans. Department of Defense (DOD) / 1000 Defense Pentagon, Washington, DC 20301; (703) 545-6700. www.defenselink.mil US Veterans Administration / Secretary of Veterans Affairs, Department of Veterans Affairs, 810 Vermont Ave NW, Washington, DC 20420; Toll-free: (800) 827-1000. www.va.gov The professional associations below offer information that serves the needs of the general public in dealing with crises, disasters, terrorism, and traumatic events. Many list local chapters and centers. Some offer information on mental health issues, referral networks of therapists, and publications related to terrorism, disaster preparedness, disaster response, and emotional wellness. Many offer links to other sites The American College of Emergency Physicians (ACEP) / 1125 Executive Circle, Irving, TX 75038, (972) 550-0911. Toll-free: (800) 798-1822. www.acep.org American Medical Association (AMA) / 515 N. State Street, Chicago, IL 60610. Toll-free: (800) 621-8335. www.amaassn.org American Psychiatric Association (APA) / 1000 Wilson Boulevard, Suite 1825, Arlington, VA 22209; (703) 907-7300. www.psych.org American Psychological Association (APA) / 750 First Street, NE, Washington, DC 20002; (202) 336-5500. Toll-free: (800) 374-2721. www.apa.org International Critical Incident Stress Foundation, Inc. (ICISF) / 3290 Pine Orchard Lane, Suite 106 Ellicott City, MD 21042; (410) 750-9600. www.icisf.org International Society of Traumatic Stress Studies (ISTSS) / 60 Revere Drive, Suite 500, Northbrook, IL 60062; (847) 4809028. www.istss.org National Association of Peer Programs /, PO Box 10627, Gladstone, MO 64188. Toll-free: (877) 314-7337. www.peerhelping.org [See p. 140.] PTSD Alliance / Toll-free: (877) 507-PTSD (7873). www.ptsdalliance.org
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State and Territory Offices of Emergency Management (OEM) There is an Office of Emergency Management (OEM) for each state and territory. Visit the FEMA website: www.fema.gov and obtain the name and contact information for your state or territory OEM. Write this information here so that you will have it handy. Name: Address: Toll free number: Local Number: Website:
Travel Safety These sources offer assistance to travelers by providing warnings, advisories, safety information, and relief services. They supply passport recovery assistance as well as legal and financial support to Americans in foreign countries. They help family members in contacting relatives in disaster related situations. Some offer links to other sites. The Office of American Services and Crisis Management (ACS) and Bureau of Consular Affairs US Department of State, 2201 C Street NW, Washington, DC 20520. American travelers’ hotline: (202) 647-5225. www.travel.state.gov
Weather This source provides up-to-date information about weather related warnings, alerts, and advisories. National Oceanographic and Atmospheric Association (NOAA) / US Department of Commerce, 14th Street & Constitution Avenue, NW, Room 6217, Washington, DC 20230; (202) 482-6090. www.noaa.gov
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Families of September 11
Families of September 11, Inc. (FOS11) is a non-profit organization founded by families of those who died in the 9/11 terrorist attacks. Membership is open to the families of victims of 9/11 and the related anthrax attacks, as well as survivors and first responders. Victims of other terrorist attacks and concerned individuals who support their mission are invited to join as associate members. FOS11 does not receive financial or other support from any political parties, campaign organizations, or the like. The group has two goals: to promote the interests of victims' families, survivors, and others affected by 9/11 (They provide information retrieval and dissemination, resource referral, research, and online chat sessions. In addition, they focus on such issues as school safety and curriculum, public trauma, victims’ assistance, and children’s issues related to terrorism and security.) to support public policies that respond to the threat of terrorism; specifically, support for the 9/11 Commission recommendations, development of appropriate agency responses, legislation related to aviation, border, port, and transportation security, and intelligence reform To learn more about FOS11 visit the website: www.familiesofseptember11.org or call: 212-575-1878 Reprinted and adapted by permission of Families of September 11 from its website.
National Air Disaster Alliance/Foundation The National Air Disaster Alliance/Foundation (NADA/F) is a non-profit advocacy group that has helped write and pass legislation to raise the standards of safety, security, and survivability. It has lobbied for the interests of survivors and developed many resources for support services. NADA/F has provided networking services for victims and developed a volunteer Family Support Team (FST) to offer direct support for survivors and family members. They have identified some unique issues affecting victims of aviation disaster: receiving insensitive, untimely, and sometimes erroneous information difficult and sometimes distant disaster site frustration in dealing with multiple agencies difficult and delayed forensics denied a traditional funeral
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Do you know there is an organization that helps victims of terrorism?
National Air Disaster Alliance/Foundation (continued) “stressful” family dynamics possible loss of multiple family members and/or friends traveling together the need to know the cause of the disaster, and learning that it was a preventable disaster crash becomes a potential platform for political, media, and special interest agendas As time progresses other difficult issues arise: lengthy, interrupted grieving process loss of privacy complex, long-term investigation and legal issues exhausting efforts to establish a memorial difficult to connect with other families from the disaster, and the need to support each other and work on common issues need for supportive assistance dealing with personal and family life after returning home To learn more about NADA/F, visit the website:
[email protected]. or call toll-free: 888-444-NADA Reprinted and adapted by permission of NADA/F from its website.
National Organization for Victims Assistance (NOVA) Do you know that today there are thousands of programs to help crime victims? One of these is NOVA, a kind of umbrella group founded in 1975. It is the oldest national group of its kind in the worldwide victims movement. NOVA’s mission is to promote rights and services for victims of crime and crisis everywhere. NOVA is a private non-profit 501(c)(3) organization of victim and witness assistance programs and practitioners, criminal justice agencies and professionals, mental health professionals, researchers, former victims and survivors, and others committed to the recognition and implementation of victim rights. They have developed a model crisis response team (CRT) to serve communities and individuals emotionally traumatized by a disaster. NOVA offers training to professionals, clergy, public safety professionals, and other community members throughout the country so that they may volunteer to serve on these CRT’s. To learn more about NOVA, visit the website: www.trynova.org or contact NOVA, 510 King Street Suite, 424 Alexandria, VA 22314 Toll-free: 1-800-TRY-NOVA Reprinted and adapted by permission of NOVA from its website.
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National Self-Help Clearinghouse
The National Self-Help Clearinghouse is a not-for-profit organization that was founded in 1976 to facilitate access to selfhelp groups and increase the awareness of the importance of mutual support. The clearinghouse provides a number of services: Assists human services agencies to integrate self-help principles and practices into their service delivery Conducts training activities for self-help group leaders and for professional facilitators of support groups Provides consultation to agencies to promote their capabilities to encourage and sustain mutual support groups Carries out research activities, including research about the effectiveness of self-help, the character of the self-help process, and relationships with the formal care-giving systems Provides information about and referral to national self-help support groups and regional self-help clearinghouses Some types of self-help groups are: Accident victim groups assist those who suffered from accidents. Addiction support groups help individuals overcome addictions. Loss of a child groups assist grieving parents to cope with their loss. Suicide survivor groups assist family and friends of those who committed suicide. Anxiety and panic attack support groups assist individuals with strategies that help. Trauma victim support groups offer assistance in a socially empathic environment. For information about where to find these groups, contact your regional, state, or local self-help clearinghouse, or the National Self-Help Clearinghouse at: www.selfhelpweb.org/ Graduate School and University Center of the City University of New York, 365 5th Avenue, Suite 3300, New York, NY 10016, (212) 817-1822 Reprinted and adapted by permission of National Self-Help Clearinghouse from its directory and website. National Voluntary Organizations Active in Disaster (NVOAD) Do you know there is a national organization that encourages communication, collaboration, cooperation, and coordination among organizations that provide disaster response, relief, and recovery? In the wake of the devastation of Hurricane Camille along the Gulf Coast in 1969, it became obvious that coordination and
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Do you know there is a national organization that helps you locate self-help groups?
National Voluntary Organizations Active in Disaster (NVOAD) (continued) cooperation among disaster relief organizations would enhance services to victims of disaster. On July 15, 1970, representatives from the St. Vincent DePaul Society, National Catholic Disaster Relief Services, Seventh Day Adventist Church, Southern Baptist Convention, Mennonite Disaster Services, Christian Reformed World Relief Committee, and American Red Cross signaled their desire to work together in times of disaster by coming together in Washington, DC where they initiated the process to form the National Voluntary Organizations Active in Disaster (National VOAD). Since that first meeting and the incorporation of National VOAD in 1975, the membership has grown to 40 members or partners with more than half faith-based. The VOAD movement continues to grow across the country with all states and territories having VOAD’s and county/parish/community VOAD’s being formed every day. National VOAD is a basis for voluntary organizations all over the nation. When a disaster does strike, National VOAD assists members and Friends of VOAD to share information and as a result enhance the coordination among the voluntary organizations. It provides a forum for collaborative planning efforts by many voluntary organizations responding to disaster. Member organizations provide more effective services with less duplication by getting together before disasters strike. Once disasters occur, National VOAD or an affiliated State/Territory or Local VOAD encourages members and other voluntary agencies to convene on site. This cooperative effort has proven to be an extremely effective way for a wide variety of volunteers and organizations to work together in a crisis. They offer valuable links to their state members and to other disaster-related sites. To learn more about NVOAD, visit the website: www.nvoad.org or contact NVOAD, PO Box 151973, Alexandria, Virginia 22315; (703) 339-5596. Reprinted and adapted by permission of NVOAD from its website. Peer Helpers Do you know that there are trained peer helpers? Many organizations and schools offer training courses to their members to become peer helpers. These are non-professional human resources who serve as support agents and educators. They provide counseling, personal assistance, and a variety of educational programs on such issues as health, prevention, and disaster response. They are not psychotherapists or medical professionals but are trained to know when and how to refer to professionals.
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THINGS TO DO p. 143 Immediately (Response Phase) p. 143 Over Time (Recovery Phase) p. 145 Anytime after a Disaster p. 147 THINGS TO THINK ANYTIME AFTER A DISASTER p. 148
DO YOU KNOW? Crisis Counseling: Yes or No? p. 159 Relaxation Exercises p. 163
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FEAR MANAGEMENT p. 150
HELP YOURSELF “There’s only one corner of the universe you can be certain of improving, and that’s your own self” Aldous Leonard Huxley 1944
“Attitude” is vital to recovery. How you think about a situation will influence not only your emotional reactions but also your physical reactions. Although a catastrophe would be a shocking experience to you, it is important to put things into perspective. When you have no control over what the environment offers you, all you can do is change yourself and react to the situation with as much flexibility as you can muster. This is not easy, but most great leaders rise to the occasion in adversity. Churchill said, “Move quickly through a crisis.” Just imagine how your own hero or role model might deal with a trauma such as yours. Modify how your role model might react to fit your own style and values. Some find that cultivating a sense of humor can do a lot for their confidence. Others find it comforting to turn to their spiritual side for support, through prayer, meditation, or the power of positive thought. Above and beyond these personal response styles, it is always important to draw strength from others. Do not be afraid to ask for help from others. Your personal support system is critical to your survival. Social support is essential to maintaining one's healthy functioning and recovery after a disaster. The following section lists the most effective ways to cope with the impact of a crisis or disaster. These responses are listed in two categories: things to do and ways to think. Choose the responses most natural and comfortable for you. 142
Most responses are effective anytime after a disaster. However, there are some responses that are only relevant soon after a disaster (Response Phase), and others that are appropriate over time (Recovery Phase.)
THINGS TO DO Immediately (Response Phase) These things to do are more intended to meet your needs soon after the disaster. Take Survival Action. Evacuate, when necessary. Rescue yourself.
Call 911. Receive emergency medical care. [See “Do You Know?” – “Evacuation vs. Shelter in Place” – in Chapter 3, p. 41. See Chapter 4 – “Do you Know? boxes – “R.A.C.E.” – p. 73 and “Evacuating a Burning Building” – p. 74.] Practice Safety. Move to a safe area away from danger. For example, evacuate the building if on fire; stay away from downed electrical wires; or after evacuating from a collapsing building, move far enough away to avoid being hit by falling debris. Watch out for danger during a disaster and avoid it.
Look:
up for falling power lines and other falling 143
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Shelter in place when appropriate.
objects
down for fire hoses, potholes, and debris
sideways for rushing vehicles and people including emergency workers
ahead because someone or something might be there in your way
Listen:
behind you for vehicles backing up
above for falling debris
Stay:
outside any area marked by yellow police tape, if you are a by-stander
away from hazardous material (Hazmat) areas
away from power lines (Don’t touch it even with a ten foot wood pole. If you think the object you have chosen to use will not conduct electricity, you are probably mistaken.)
Take care of your basic needs. Maintain fluid intake and nourishment. Protect yourself and/or others from the elements by seeking shelter. Keep warm. Take care of your mental health and social needs. Receive psychological first aid. Accept social support.
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Reunite with your friends and loved ones. [See “Do You Know?” – “Reunion vs. Safety and Security” – in Chapter 5, p. 96.] When you feel panicked or stressed out, take deep breaths slowly from your belly. Imagine yourself in a calm, clear state of mind. Identify your first priority and focus on dealing with that problem.
Reach out to available agencies to obtain immediate resources to solve your problems and meet your needs, for example, to obtain food, clothing, temporary shelter.
Over Time (Recovery Phase) The following actions and strategies are intended to aid the healing process in the aftermath of the disaster. Give yourself time to heal. Avoid certain types of major life decisions. For example, if your house has burned down, you should focus on the immediate response, such as contacting your insurance carrier, rather than worry about where you are going to live long-term and all the details of reconstructing your life. These decisions can be dealt with later. Reach out for agencies to get funds for your recovery, for example, to repair your damaged house. Make a plan to solve the problem. 145
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Deal with things one at a time, hour-by-hour, and then day-by-day.
What is your goal? What do you need to achieve it? Who can help you? What needs to be done first, second, third, etc? How will you know you have completed your goal? Get feedback to help you understand the meaning of this event and how it affects your life. Fill your life with music and art. These creative gifts from the masters provide “food for the soul,” unmatched by other more basic activities. Take walks, exercise, or meditate to reflect on positive aspects of your life. If you are religious, consider celebrating gratitude for your blessings in prayer. Be kind to yourself. Give yourself breaks or quiet moments. Reach out to loved ones and friends. Go to the movies or do some light reading. Eat and drink pure foods and water. Avoid self-medication, alcohol, and drugs. Stay in touch with friends and family. Communicate and reach out for support from others. Pets can be a great comfort to traumatized individuals. Play with your pets or, if possible, adopt one. If you are unable to have a pet, consider volunteering at an animal shelter. If possible, and if you have the strength, find something to laugh about each day. Sometimes a crisis or catastrophe puts life’s priorities in perspective. Often 146
this is the time to let go of emotional baggage from the past and begin to forgive others. Try to help others. It is beneficial to your recovery to give to others, when you have the strength to do so. While reaching out to others, you will heal by contributing to their lives.
Anytime after a Disaster These things to do are intended to be used anytime after a disaster. They are general strategies. Get as much accurate information as possible from reliable sources such as emergency management personnel on the scene. Express feelings to someone whom you trust, such as a crisis counselor. Explore your support systems and make plans to contact relatives and trusted friends for comfort. Find and contact key agencies that can offer support. These include the Red Cross, The Salvation Army, FEMA and other agencies. [See Chapter 7 – “Seek Help” – p. 126.]
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After time has passed, it becomes easier to focus on the “big picture.” This is a good time to initiate some social action – getting legislation passed, advocating for disaster victims, establishing or joining an advocacy group, etc. Some of the agencies engaged in social activism which are listed as resources in Chapter 7 were started by victims of tragic events.
Use stress management techniques. [See “Do You Know?” –“Relaxation Exercises” – in this chapter, p. 163. ] Get sufficient rest whenever possible. Talk to others about what has happened. Engage in healthy behaviors. This enhances your ability to cope with excessive stress. Exercise. Pursue relaxing leisure activities. Perform relaxation exercises. Avoid drugs and alcohol. Meditate. Use biofeedback. Consider seeking hypnotherapy. Change your physiology (face: from frown to smile; posture: from rigid to relaxed, from bent to erect).
THINGS TO THINK ANYTIME AFTER A DISASTER These are thoughts and attitudes that can help you to stay calm, plan some recovery strategies, and keep your faith. They are useful anytime after the event. It is okay for your thoughts to seem empty. It is also natural to go into the “pretend it didn't happen mode" to protect yourself from the event. In your mind, stay in the moment, but prepare for the future.
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Challenge your negative beliefs. Replace such thoughts as, ”I always have bad luck…, nothing will be better from now on…, everything sucks,” with, “How could I know that…, is there any real reason to think that…, maybe things will change for the better.”
Think of previous ordeals that you have successfully overcome and use these as a “power base.” Imagine a way you would like to get through this time of crisis. In your mind’s eye, reactivate a previous ordeal that you have overcome. Think of what you did to get through that crisis. Use similar strategies to deal with the current situation. Tell yourself to relax and breathe low and deep. Remind yourself to practice stress management techniques. As you imagine worst-case scenarios, try to think of alternative outcomes, for example, “I can see my friends…, I can get back into my routine…, I can enjoy the little things in life.“ Think of a positive role model, someone you admire in your own life or in public life, and visualize this person facing your disaster. Imagine what he might think to deal with it more effectively. Based on your style and personality, borrow and use his thinking strategies.
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Adjust your self-talk. Replace negative messages with positive messages, for example, from, “No way! I’ll never get through this,” to “I can do this…, it is okay to feel scared, but I can take the edge off by breathing deeply and taking a stress break.”
Remember how things change over time. For example, try to recall a previous crisis in your life and, as you look back, remind yourself that now it seems less catastrophic. If possible, imagine how you will look upon this event in the future. Think of something positive to do to help yourself to return to normal activities after the disaster has subsided.
FEAR MANAGEMENT “Nothing is so much to be feared as fear.” Henry David Thoreau 1851
“The only thing we have to fear is fear itself.” Franklin D. Roosevelt 1933
Since September 11, 2001, Americans have gained a greater awareness of their vulnerability not only to terrorist attacks but also to other disasters. As a global community, we experience the ever-present worldwide threats of disasters. Via the internet, we learn instantaneously what is happening around our planet. We witness the suffering of others as the media broadcasts live video of the latest catastrophe. In the face of disaster and terrorism, we can allow fear to dominate our lives, or we can control our fear. Fear management is a method to control our fear. It helps us cope with our anxiety during heightened Homeland Security terrorist alerts and natural disaster warnings. This method allows us to overcome our complacency, maintain our vigilance, and be ready without becoming overwhelmed. 150
We offer you our FEAR NOT mnemonic to help you learn and remember the basic strategies of fear management.
Focus on possible dangers. Be vigilant. You actually increase your safety if you think about dangers rather than if you live in denial. Nevertheless, being mindful of what might happen does not mean that you have to replay the worse case scenario over and over in your mind. Balance is important. Avoid the extremes. Terence advised, “Moderation in all things.”
Scan around you. Think and behave like security and safety experts. For example, when a security expert walks through a parking garage, she notes the locations of the exits, stairwells, and the alarm buttons. When a safety expert stays in a hotel he locates the fire exits. In addition, he notes how far the nearest exit is from his room and what route he needs to take from his room to the exit. By performing similar actions, you key your mind on the safe harbors.
Assess risk. How likely is it that something will happen? In the beginning of Chapter 1, we asked several questions to help you assess risk. By knowing the frequency of various events, you can place your fears about what might happen into a proper perspective. People usually dread that a “big one” will occur, but do not give much thought to the many dangerous things that happen on a daily basis and that can be prevented. Although you should prepare for terrorist attacks, you should also focus on the more common traumatic occurrences. For example, most people do not worry about driving. However, driving is dangerous. Motor vehicle accidents hap151
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Examine the environment.
pen frequently. As a society, we have benefited when we have reduced everyday trauma and its consequences. For example, by the increased use of seatbelts, motor vehicle accident injuries and fatalities have greatly decreased. In addition, we can reduce the number of accidents by driving safely.
R estructure your thoughts. “I have a new philosophy: I’m only going to dread one day at a time.” Charles Schulz, Charlie Brown in “Peanuts”
As human beings, we often make faulty assumptions and process information in ways that work against us when we try to manage our fear. Nevertheless, by being aware of these possible pitfalls in our thinking, we can restructure our thoughts to our advantage. What are these assumptions and thought processes, and how can they be corrected? We present a list of things to do or think. We also provide descriptions of the false assumptions or unproductive thought processes that are corrected by following the strategies below. Trust your intuition. We think too much. Sometimes it is good to ponder an idea or thoroughly analyze a situation; sometimes is it better to act on intuition. Our intuition is the best tool that we have to alert ourselves to potential danger. Nevertheless, we are capable of talking ourselves out of our hunches and “reasoning” away our concerns. In certain situations, “thinking too much” can be dangerous. You may see that something is out of place, notice an apparent contradiction, sense that something is “just not right,” or feel uneasy “in your gut.” These are situations when it is best to “lose your mind and come to 152
your senses!” Check out your suspicion on your own, if it is safe to do so, or notify the proper authorities. A few months after 9/11, one of the authors noticed a canvas bag sitting on a stoop as he was about to enter a local high school. Without touching the bag, he peered into its open top and was able to read handwritten notes on “bomb making.” He immediately notified the police officer inside the school. Although it turned out that the bag belonged to a student taking a class on terrorism and this “suspicious package” was not dangerous, it was better to be safe than sorry if it really had contained an undiscovered bomb that caused massive destruction.
We dwell on the negative. Some individuals even “catastrophize,” that is, constantly imagine the worse case scenario. There is no question that bad things happen. Nevertheless, many good things also happen and you can lessen your fears if you focus on, engage in, and enjoy these good things. Avoid jumping to conclusions. We misuse logic. It seems as if our brains are hardwired to automatically think of explanations for what occurs around us. Just because an event precedes another event, we often assume that the first event caused the second. Even without any proof, we act on false cause-and-effect assumptions. When combined with negative thinking, this logical fallacy can generate enormous worry. For example, if we were to see a van speeding down the street and then hear an explosion, we might assume that the occupants of the van were responsible for the explosion. Our negative thinking might lead us to conclude that terrorists were in the van and, thus, 153
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Emphasize the positive.
the explosion was an attack. We would become very frightened. Later, we might learn that the explosion was accidental and unrelated to the van. Therefore, it is better to challenge your assumptions rather then jump to conclusions. Place statistics in perspective. We are poor natural statisticians. We often go about our daily routines with an attitude that “nothing will ever happen to us.” However, after a traumatic event does happen, we go to the other extreme and fear that we are in constant jeopardy of a recurrence. This fear is particularly pronounced if we were impacted directly by the traumatic event. Once we have experienced a trauma, we may even develop an “attentional bias,” that is, sensitivity towards trauma-like stimuli. Therefore, we sense imminent danger when there is no real threat. You should keep in mind that statistics demonstrate that events have a particular probability of occurring, and the fact that a person has experienced an event does not mean that she will experience the event again. “Lightning doesn’t strike twice” is a saying that expresses the low probability of a person repeatedly experiencing an event, although Roy C. Sullivan is on record for having been struck by lightning seven times. The good news is that he is the “exception that proves the rule,” and lived to tell of each and every experience. Obviously, if you continue to live in a place that is at risk for certain disasters, such as hurricanes in Florida, then you will be more likely to have repeated encounters with hurricanes over your lifetime. In addition to this all-or-none error, we often misunderstand probability in general. For example, each of the events listed in Chapter 1 has a 100% chance of happening at some 154
time in the future. How frequently it might happen and how many people might be involved are entirely different statistics. Shortly after 9/11, a terrorism expert stated that there would be a 100% chance of another terrorist attack. At that time, some people interpreted this to mean that another attack was imminent and that they would definitely be victims. To place the “100%” figure in perspective, it is worthwhile using a lottery analogy. On the one hand, the chance of someone winning a lottery is 100%. The amount of the jackpot may build up over several weeks because there have been no winners. But as people continue to play, someone eventually wins. On the other hand, the chance of a specific person winning a lottery could be as high as one in about 135 million.
We assume that whatever is unknown and seems uncontrollable is more dangerous, even though intrinsically it is not. For example, tobacco smoking is very familiar and can be controlled; terrorism is viewed as unknown and uncontrollable. Nevertheless, smoking tobacco is more deadly. In the United States, international terrorist incidents from 1991 to 2000 caused, on average, one fatality every 260 days, but a tobacco related death occurred every 1.3 minutes. Remind yourself that terrorism is not new. It has been around in an organized form for at least several hundred years, perhaps starting when one group of people catapulted plague infected corpses into the midst of another group. Reading the quotations in this guide may also help you gain a healthy perspective. These quotes can reduce your fears by providing a connection to the past. For example, President Roosevelt’s 1933 admonishment at the beginning of this section reminds you that former generations faced and conquered similar daunting circumstances with resiliency. 155
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Learn from history.
Remind yourself that you can be safe without
controlling everything. We assume that what we cannot control will be a threat to us. In this case, you should remind yourself that many natural events take place beyond our control but are harmless. In fact, many occurrences outside our control are actually beneficial. Work on what you can control. We worry about what we cannot control. If you are concerned about “control,” it helps to separate “good” worry from “bad” worry. “Good” worry motivates. When we engage in “good” worry, we take action that will benefit us. For example, worrying that you might fail an examination motivates you to study so that you increase your chances of passing it. “Bad” worry is dwelling on something that your worry will not change. It wastes your time. Apply Reinhold Niebuhr’s serenity prayer – “God, give us grace to accept with serenity the things that cannot be changed, courage to change the things that should be changed, and the wisdom to distinguish the one from the other.” Therefore, why not spend your energy changing what is under your control? Think that maybe “size does not matter.” We think that size alone defines the characteristics of something. In other words, we assume that if something is bigger, it is totally different from something smaller. After 9/11, it did not calm the fears of Americans for us to hear pundits say: “Nothing like this has ever happened before.” “This is a whole new ballgame.” It was the immensity of 9/11 that made it appear entirely different. When confronted with something so massive, our previous successes in overcoming disasters on a smaller scale may do little to reassure us. It 156
appears to be totally “unknown,” and the “lessons learned” from battling other disasters do not seem to apply. If you are in this state of mind, you should particularly look at Chapter 3 “Learn What to Expect” and Chapter 5 “Learn How We React.” Although disasters produce chaos, they follow certain patterns. Our collective emotional reactions, and the principles of disaster response and recovery are the same no matter what the size of the disaster. Finally, if you are not convinced by this “size does not make a difference” argument and are still frightened, all you need to do is look back in history. The attack on Pearl Harbor on December 7, 1941, although different from 9/11, was equally sudden, massive, and devastating.
We think that what we experience is unique. In many ways, that is true. Nevertheless, there is a commonality about trauma and tragedy that we can all experience and share. If you focus only on the uniqueness, you feel alone and different. This increases your fear. Express your fears to others, share your experiences, and gain support.
Natural protection: Accept that fear is protective. Fear is not bad. We admit that our mnemonic might be misleading in this respect. We do not believe it is safe or healthy to live without fear. Fear and also anxiety are instinctive emotions that protect and even motivate us. However, there are optimal levels of fear and anxiety. Too little can leave us unprepared. Too much can interfere with our functioning. Humor and faith can counteract excessive fear and can be protective in the face of disaster and terrorism.
Observe particular principles. 157
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Focus on the universal aspects of your experiences.
By practicing two sets of principles – prevention and preparedness, safety and security – you can become proactive and lessen your fear. This guide provides you with many specific strategies that you can use in order to put these principles into action
Threat alarm: Use how your mind/brain works to your advantage. Knowing how something works dispels the mystery; we are reassured. We can either think of our minds/brains as “black boxes,” the contents of which are unknowable, or we can learn what scientists have discovered about how they work. We can use what we know about the psychobiology of fear and anxiety to better control our feelings. For example, it is comforting to know that our brains contain a threat alarm or fear circuit that protects us from life threatening danger. Joseph LeDoux, a neuroscientist, identified the amygdala, two small almond-shaped areas on each side of the brain, as the key components in this fear circuit which also processes sensory input and produces the startle response and fightflight-freeze behavior. The amygdala monitors our environment for danger. If you step off the curb just as a truck is speeding down the street, this system senses the danger and causes you to automatically jump back in a matter of milliseconds without any conscious thought. However, there is a downside to possessing this threat alarm system. It works well only in regard to direct threats. In addition, it can condition us to fear non-threatening stimuli. But we have another brain function – thought – that we can use to modify our conditioned fear. A key player in this function is the medial prefrontal cortex that interacts with the amygdala and modulates its activity. Therefore, our thinking can relieve our fear.
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Thought restructuring strategies, like those above, work to control and lessen fear.
DO YOU KNOW? Crisis Counseling: Yes or No?
During the aftermath of a disaster or terrorist incident that affected you, someone may likely approach and offer you crisis counseling. Since your participation in any type of psychological counseling is voluntary, you need to decide whether to participate. What do you need to know in order to make an informed decision?
Crisis Counseling and Crisis Intervention Crisis counseling is an umbrella term used for any type of psychological intervention during a crisis or after a disaster. These interventions are not treatments or therapies although they may facilitate healing. Crisis intervention is a specific method that developed out of the work of two psychiatrists – Erich Lindemann, M.D., who studied the survivors of the tragic 1942 Cocoanut Grove nightclub fire in Boston, and Gerald Caplan, M.D., who worked primarily with families in crisis. The dual goals of this method are: 1) to reduce the impact of the stressful event, and 2) to help individuals not only solve the present problems but also enhance their ability to cope with future adversities.
Psychological Debriefing Psychological debriefing (PD) is a one-time structured activity to process trauma by talking about the experience. 159
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Do you know that you may need to decide whether to participate in crisis counseling?
The purpose of this activity is also to provide information about traumatic stress and stress management. The debriefing is usually done as a group activity that is directed by facilitators. It takes place ideally between 24 and 72 hours after a traumatic event, but can be performed within weeks of such an incident. There are different versions of PD. There is an ongoing debate in the field of disaster mental health about the use of PD. The International Critical Incident Stress Foundation supports the use of a particular type of PD called Critical Incident Stress Debriefing (CISD), which is the most widely used method. Other experts in the field warn against using CISD or any PD method because PD may be harmful. What is CISD? In 1983, Jeffrey Mitchell, Ph.D. designed a group PD method consisting of a seven phase process to be used by emergency personnel – emergency medical technicians, firefighters, paramedics and police – after a critical incident, for example, being confronted with a fatality while performing their duties. Initially, experts had hoped that PD would prevent the development of posttraumatic stress disorder (PTSD) after exposure to a traumatic event. Presently, there is no scientific evidence that any intervention – either psychosocial or medication – shortly after a traumatic experience prevents the development of PTSD. Nevertheless, research studies of PD demonstrate that most of the individuals who have participated in psychological debriefings have been satisfied and found them useful. Recently, a few studies have demonstrated that individuals who were highly aroused at the time of the PD actually fared worse than other highly aroused individuals who received no intervention. In response to this 160
Over the years, the use of CISD has spread widely as a onetime intervention. It was originally developed for members of pre-existing groups, such as people who work together. In addition, these co-workers likely experienced the traumatic event together. Now CISD is also used inappropriately for individuals who do not comprise a pre-existing group but are put together for a PD only because they have been involved in the same disaster. For example, strangers should not be together in a PD just because by chance they came to the same evacuation center. In addition, the trained PEER counselors who conduct this intervention are required to work with and be supervised by mental health professionals. Although the ICISF officially sanctions CISM teams to perform interventions for emergency personnel, there are freelance teams which respond to aid disaster victims, but which are not comprised of mental health professionals and do not have proper supervision. We recommend that you avoid interventions conducted by these unofficial teams.
What should you ask? There is some important information that you should find out. If the person in charge does not provide this information, you should raise some questions. First, when you are directed to participate in a “debriefing” you should ask, “What is the purpose of the meeting?” It might not be a PD but a briefing, that is, a way to provide the available facts of a disaster to those who need to know. For example, an airline will hold periodic briefings with the rela161
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data, ICISF has emphasized that CISD is not meant to stand alone as a one-time intervention. It should be part of an entire program called Critical Incident Stress Management (CISM) that has multiple components.
tives of the passengers after a commercial aviation disaster. The meeting might also be an educational forum to provide information about available resources and the procedures for obtaining aid. For example, the staff at a family assistance center might hold such an educational meeting. Second, if you are offered any type of crisis counseling, including a PD, you should ask: “Who is sponsoring it?” “Who will conduct it?” “What training do the leaders have?” “What are their credentials?” “What is the expected result?” “Are there any potential adverse effects?” “How will confidentiality be maintained?” After receiving the answers to these questions, you can make your decision whether to participate. If you have any doubt, avoid participation.
Psychological First Aid There is a consensus developing among disaster mental health experts that psychological first aid is the preferred psychological intervention in the immediate aftermath of a disaster or terrorist incident. This method emphasizes protection and support. It is used to lessen the psychological injury and reduce the physiological reaction to a traumatic event. It consists of protecting the survivor from further harm, reducing the emotional and bodily arousal triggered by the trauma, mobilizing support for those who are most distressed, keeping families together or facilitating reunion with loved ones, providing information, and fostering communication and education. This method differs greatly from crisis intervention and PD, because it does not require the survivor to talk about the traumatic event.
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Relaxation Exercises Do you know there are a variety of relaxation techniques that will help you control your stress in the face of a disaster or trauma? Here is an example:
The following is the generic technique taught at the Mind/Body Medical Institute: 1. Pick a focus word, short phrase, or prayer that is firmly rooted in your belief system, such as "one", "peace", "The Lord is my shepherd", "Hail Mary full of grace”, or "shalom". 2. Sit quietly in a comfortable position. 3. Close your eyes. 4. Relax your muscles, progressing from your feet to your calves, thighs, abdomen, shoulders, head, and neck. 5. Breathe slowly and naturally, and as you do, say your focus word, sound, phrase, or prayer silently to yourself as you exhale. 6. Assume a passive attitude. Don't worry about how well you're doing. When other thoughts come to mind, simply say to yourself, "Oh well", and gently return to your repetition. 7. Continue for ten to 20 minutes. 8. Do not stand immediately. Continue sitting quietly for a minute or so, allowing other thoughts to return. Then open your eyes and sit for another minute before rising. Practice the technique once or twice daily. Good times to do so are before breakfast and before dinner. Benson’s Relaxation Technique reprinted by permission of HELP the Mind/Body Medical Institute. www.mbmi.org
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Benson’s Relaxation Technique The relaxation response is a physical state of deep rest that changes the physical and emotional responses to stress (e.g., decrease in heart rate, blood pressure, and muscle tension). If practiced regularly, it can have lasting effects when encountering stress throughout the day and can improve health. Regular elicitation of the relaxation response (RR) has been scientifically proven to be an effective treatment for a wide range of stress-related disorders. In fact, to the extent that any disease is caused or made worse by stress, the relaxation response can help. Elicitation of the relaxation response is not difficult. There are two essential steps to eliciting the RR: Repetition of a word, sound, phrase, prayer, or muscular activity. Passive disregard of everyday thoughts that inevitably come to mind, and then return to your repetition.
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THINGS TO DO p. 165 Immediately (Response Phase) p. 165 Over Time (Recovery Phase) p. 167 Anytime after a Disaster p. 167 THINGS TO SAY AND AVOID SAYING ANYTIME AFTER A DISASTER p. 169 Things to Avoid Saying (Not Helpful or May Be Harmful) p. 169 Things to Say p. 171 GROUPS WITH SPECIAL NEEDS p. 171 ABC’s of Caring for Children p. 171 Accommodating the Physically Disabled p. 179 Caring for Seniors p. 180 Collaborating with People with Serious Mental Illness p. 1181 SELF-CARE WHILE YOU HELP OTHERS p. 181
DO YOU KNOW? Donations for Disaster Relief and Recovery p. 182 Volunteering: Helpful or Dangerous? p. 183
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HELP OTHERS “What do we live for if not to make the world less difficult for each other?" George Eliot circa 1871
Below are the most effective ways of responding to others. These responses are listed in three categories: 1) “Things to Do, 2) “Things to Say and Avoid Saying”, and 3) “Groups with Special Needs.” Choose the responses most natural and comfortable for you. Most responses are effective anytime after a disaster. However, there are some responses that are only relevant soon after a disaster in the Response Phase and others that are appropriate over time in the Recovery Phase. In addition, this section includes “Self-Care While You Help Others.”
THINGS TO DO Immediately (Response Phase) These things to do are more intended to assist another indi165
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Your support of others offers hope and helps them develop resiliency. Whether they are friends, relatives, coworkers, or strangers, your help is important to their emotional well-being. Research suggests social support during the exposure to or during the recovery from a traumatic event may reduce the possibility of an individual developing Posttraumatic Stress Disorder. Your greatest gifts to others sometimes go unrecognized until time has passed. After their recovery, they may remember you as a comforting and supportive figure. And, you will also find that giving to others will promote your own learning and healing.
vidual with safety issues and to reach out to meet the person’s needs soon after the disaster. Take survival action. Lead others out during an evacuation. Rescue, if possible. Attend to those who need assistance, without endangering yourself.
individuals who have collapsed
individuals who have signs of acute distress
individuals who are injured Assess
vital signs (breathing and pulse)
for injuries
Administer
CPR, if individual is unresponsive and in pul monary arrest or cardio-pulmonary arrest, if certified
First Aid, if certified
Get emergency medical or surgical treatment for those in need. Address psychological needs. Scan the area for emotionally distressed individuals who may need help. Respond to distressed individuals and offer to help. If survivors appear very distraught, move them away from others, if possible, while talking calmly with them. Help move emotionally distressed victims who are immobilized to safety. Help others to tolerate sheltering in place, when sheltering in place is necessary.
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While offering emotional support, observe for and inquire about any medical warning signals such as shortness of breath, dizziness, or chest pain. If necessary, seek medical assistance. When possible, reinforce the fact that safety is being secured. Upon request, seek information about the condition of loved ones or friends.
Over Time (Recovery Phase) After time has passed, these recovery actions help others return to their normal routines. As someone taking a supportive role, you should encourage survivors to engage in the following self-care activities. Maintain routines. Organize memorial events, share meals, and build monuments.
Take stock periodically by rating stress level, sleep, job or school functioning, and relationships. Use a 1-10 scale to determine any of these areas that need further attention. Periodically review recovery plans.
Anytime after a Disaster These things to do are intended to assist others anytime after a disaster. They are general helping skills. Arrange for health and mental health care needs. Do not administer any medical procedures that require training and certification unless you possess those qualifications. 167
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Read self-help books on coping with disasters and crises.
Provide whatever accurate information you have in answering the individual’s questions. If someone is reacting emotionally, tell him that it is normal to be upset, and if he were not upset, you would be very concerned about the way he was coping. Empathize and re-assure. Listen actively by making eye contact and tuning in to the other person’s physical and mental state. Use the person’s name when you speak to her. Encourage the person to express feelings. Be non-judgmental. Be supportive but avoid enabling. Honor different cultures and beliefs. Be sensitive to the ways various cultures might react to a situation. Resist promoting your way of reacting as the only way. Find out about the victim’s support systems and encourage him to contact relatives and trusted friends for comfort. Assist the victim to contact key agencies that can offer support. These include the Red Cross, The Salvation Army, FEMA and other agencies. [See Chapter 7 – “Seek Help” – p. 104.] Encourage the victim to tolerate uncertainty in the immediate future. If you are trained in stress management techniques and the victim is willing, you may instruct and coach him to perform a relaxation exercise. [See “Do You Know?” box – “Relaxation Exercises” – in Chapter 8, p. 163.]
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Silent support, often called witnessing, is a powerful way to connect with people, and is more effective than hollow conversation. Listen, listen, listen!
THINGS TO SAY AND AVOID SAYING ANYTIME AFTER A DISASTER “Speaking without thinking is shooting without aiming.” Anonymous
Most of all, how you deliver your verbal responses is critical to the way they impact others. Your message is only effective if your receiver defines it as such. Establish rapport. Show concern and be gentle. Your sincerity and authenticity are essential to the well-being of those you reach. Remember that the impact of your message is defined by the way others respond. Nevertheless, do not expect all victims to embrace your attempts to reach out. Many victims may be too upset to listen.
Things to Avoid Saying (Not Helpful or May Be Harmful) This section appears first because there are a number of verbal responses that can intensify trauma and anxiety in those facing critical incidents. It is important to use good judgment and resist the urge to rush in and “fix the problem.’’ That is why we are identifying some of the responses 169
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The words you say in the midst of crisis situations are especially powerful. The right ones can help a survivor acquire the most effective emotional state to cope with a traumatic situation. The wrong words can completely undermine a person’s ability to cope. The ways of using words described below are intended to strengthen individuals and assist them to cope with trauma.
that can be ineffective or damaging to the victims you address. We present some things that many people often say and the reasons not to say them. “I understand.”– Only the person having the experience can truly understand it from their own perspective. “You’re lucky you survived.” – A person who has been traumatized or who has lost a loved one does not feel very lucky. “The good die young.”– It all depends on your beliefs about the spiritual realm. It is hard to match your beliefs with another’s, so don’t try. “The angels took your loved one to heaven.” – The person might have a different belief and such a remark could backfire and spur anger. It is better to check first with the person to determine his beliefs or attitudes towards religion. “It could be worse.” – The person will not believe this after enduring such a traumatic event. “Let me tell you what happened to me.” – At this critical time the victim is not interested in hearing the helper’s trauma story. “You need to get on with your life” – The person is not able to even think of the future. He needs to stay in the moment and process what has happened. By suggesting that he move on, you may rob the survivor of the necessary steps in the process of grieving or recovering from the trauma. “You think this is bad. I’ve been through worse.” – The person will feel you are competing with him in a “biggest victim/worse disaster contest.” 170
Things to Say This section identifies some responses which can make others feel more comfortable or process the event in constructive ways. “What can I do to make you more comfortable? – An obvious way to present yourself as someone who cares. “I can only imagine how horrible this must be for you.”– This approach validates that you are not trying to second guess the person’s exact feelings. It gives the person room to deal with the situation in his best way. “This wasn’t your fault.” – Many victims feel guilty that they have survived and others did not (survivor guilt). They think they should have done something to save other people. “If only I had…..” This response lets them know that they are not responsible. It may help to reduce their guilt. (Note: This applies only to people who have not actually caused or contributed to the negative event.)
“Things may never be the same, but they can improve with time” – This helps to put things into perspective and gives someone hope for the future. It can also start the healing process. “Believe it or not, I might understand. Something like this happened to me.” – There is an appropriate time and a proper way to let the victim know that he is not alone, that is, others have had similar experiences.
GROUPS WITH SPECIAL NEEDS ABC’s of Caring for Children 171
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“You are safe now.”– Say this only if she is really out of danger.
Age Appropriate: Children respond differently at different ages. What is appropriate for a toddler would certainly not be appropriate for an adolescent. Therefore, you should individualize your responses to each child according to her age. An adolescent may cope by being involved with her peer group – for example, scouts, candy-stripers, etc. – but a younger child would obviously not have these support systems and will need your individual attention. Talk at her level. Avoid technical terms a young child would not understand. Do not use very simple words with teenagers since they may view this as patronizing and possibly even insulting.
Balance: A key principle of stress management, and for living one’s life in general, is balance. Extremes can be distressful and even dangerous. Everything in moderation is a good rule. For example, you do not have to eliminate your child’s TV watching. It is okay for an older child or adolescent to watch TV news or other programs about the disaster. However, put some limit on the amount of time your child spends watching these programs. Watch the TV news with him, discuss it, and then engage him in other activities.
Care for Yourself: Several studies have demonstrated that a child’s distress level frequently mirrors her parents’. Therefore, caring for yourself is the first and foremost way of helping your child. [See Chapter 8 – “Help Yourself” – p. 141.] By getting your distress under control, you serve as a role model for your child. Your behavior shapes your child’s behavior.
Dreams: Teach your child that dreams are not mysterious. You should say, “It is only a dream. It is not real, but it can mean something to you.” There is even a study that 172
demonstrates that individuals may be able to control and change the content of their dreams. Talk with your child about his dreams, if he feels comfortable about revealing them to you. An older child can study his dreams and learn their personal meaning. This can help him put the ordeal into perspective.
Emotion and Empathy: Feelings are okay. They are natural. Feelings are genuine. Although what we might feel may be out of proportion to a particular situation, it is still how we feel. You may not agree with how your child feels about what has happened because you feel differently about it. Although you may not agree with your child’s feelings, you can empathize, by imagining her point of view. Be sure to respect her feelings. Do not attempt to talk her out of her feelings. might not have. Therefore, a major role for you is to facilitate what is necessary for your child to cope. For example, if your young child expresses the need to raise funds for the disaster victims, make it a project for both of you so that you may guide him. If your adolescent wishes to volunteer his services, call a co-worker whom you know volunteers for a disaster relief organization, and arrange for your child to meet with him.
Gifts: A gift is doing something special without needing to be asked. Even though you regularly give to your children, this is an especially significant time to give. Your gift might be to go on that day trip you were planning together but have been too busy to do. Your gift could be doing what she really likes, even if you do not enjoy it. For example, see a children’s movie.
Hugging and Holding: These need no explanation. 173
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Facilitate: As an adult, you have abilities that your child
Individualize: “One size does not fit all.” Each child may need something different because of his personality and temperament. There is more than one way to react and cope with tragedy and trauma. One child may cope best by maintaining some solitude; another child by being socially involved.
Join Together: Spend more time with your child. Doing family activities, especially at a time of tragedy and trauma, is very supportive and reassuring.
Kindness: Show your kindness to others, especially those in need among your neighbors. Children learn by example. This is the time to be especially kind.
Love: The lyrics of the Beatles song state, “All you need is love, love, love is all you need.” Demonstrate and express your love for your children.
Meaning: There are two “meanings” in regard to experiencing trauma. The first is the specific meaning the trauma takes on for the individual. This is usually the answer she seeks to such questions as, “Why me?” or “Why did this happen?” “What can I learn from this to improve my life?” There is a larger meaning that has to do with one’s life viewpoint and beliefs. This meaning exists before one is exposed to the trauma and shapes how one answers the questions previously stated. This meaning involves one’s culture and religion. It relates to spirituality. When faced with tragedy and trauma, affirming the family’s shared values or religious beliefs provides comfort and hope.
Normal Reactions: Most reactions are natural and temporary. A very young child may regress, that is, go back to former behavior. For example, a toddler may return to thumbsucking or lose bladder and/or bowel control after having 174
been toilet trained. A latency age child (6 through 11 years) may bed-wet or cling excessively. Avoid over-reacting to or punishing your child for these behaviors. Give your child extra attention and care. Help him to regain his most appropriate behavior. An adolescent, for example, may withdraw or become irritable. Show him you care by helping him “weather the storm.” “Normalization” is the act of reassuring another that his behavior, thoughts, or feelings are natural or normal reactions to a situation. For example, to “normalize” your 16-yearold’s reactions, you might say, “ I can see why you’re out of synch, but please don’t take it out on me.” For your 10-yearold, you might offer, “It’s okay to be sad. I’m sad too.” self that she is having a normal reaction to a traumatic event, or to detect warning signs of difficulty. Intense and/or persistent reactions should be professionally evaluated. Intervene and get help if there is use of alcohol or drugs. If you have any question or concern about your child’s reaction, consult an appropriate health or mental health professional.
Process and Play: Reacting to and recovering from a disaster is a process. Do not expect everything to immediately return to “normal.” Play, for a younger child, is a way to process his experience and relieve tension. It also helps a child gain mastery over an otherwise overwhelming event. For example, in reacting to the attack on the World Trade Center, a young child may have needed to repeatedly build two tall towers out of blocks, only to angrily “knock them down.” Allow your child to process the disaster. Such behavior may make you uneasy, but do not stop it, although you 175
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Observe: Watch your child’s behavior to reassure your-
need to intervene if his behavior becomes genuinely destructive.
Questions and Respect: Encourage your child to ask questions. Do not bar questions or change the topic when she asks a question. You may also ask questions, but do not interrogate your child. Make yourself available. Listen, listen, listen! This allows your child to express her thoughts and feelings, and process her experience. Remember to use the principle of “balance.” There is a time to ask questions, a time to encourage your child to talk about her experience, and a time to respect her silence.
Routine and Ritual: Children need structure and support. Therefore, maintain your regular routines and schedules as much as possible. Try to continue to observe your family rituals, such as birthday celebrations, annual barbecues, or religious observances.
Safety and Security: A major task for you is to keep your child safe and secure. [Follow the safety and security procedures in Chapter 3 – “Prevent” – p. 29.]
Talking, Truth and Timing: Talk to children truthfully. You may wish to use the opportunity of a disaster to teach your child some truths about life. Parents are protectors of their children. When a child is young, you can hold his hand to prevent him from running into danger. When he is older, you cannot constantly guard him or physically rescue him from every threat. You can only hope that he will use what you have taught him to protect himself. We often automatically utter statements that might not be true. For example, “Everything will be all right” is a lie unless you are positive that it will. “There is nothing to worry about” is a lie if there is something to worry about. Children 176
can often sense that there is something wrong or that you are upset. They just might not know what is wrong or what is upsetting you. Therefore, it will only distress your child if you falsely reassure her. In addition, she will likely learn from another source what you have withheld. Isn’t it better to have her learn the truth from you, so that you can be emotionally supportive and give her guidance?
Timing is important. For example, a good method to convey “bad news” to anyone is to do it in small doses over time, if possible. This allows the person to adjust rather than to be shocked. How do you know when it might be a good time to give your child information? Your child’s asking you a question is one indication of the correct time. Nevertheless, it is best that you only answer the question he is asking so that you do not overwhelm him with too much information. You may ask questions to clarify what your child is really seeking. Remember to give age-appropriate answers. Express your feelings if you are comfortable doing so. Hearing that “mommy and daddy are sad” but seeing that they are still functioning sets an excellent example. Such behavior is normalizing. Talking truthfully to your child also gives her an opportunity to express her thoughts and feelings.
Understand: To take care of children, it helps if you understand them, that is, be thoroughly familiar with their makeup, with “what makes them tick.” Learn the normal behavior that children exhibit at various stages of develop177
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You can be informative and truthful without “letting it all hang out.” You do not have to blurt out all the horrible details. You can often say things in a way that is reassuring and hopeful.
ment. Learn the natural responses children might have to trauma. [See the table – “Children’s Reactions To Disasters” – in Chapter 5, p. 100.] Know your child’s individual characteristics. What is he usually like? How does he behave when he is ill? What motivates him? What are his interests? Is he a quiet person or a talker? Etc., Etc., Etc. You can use this knowledge to help your child prior to, during, and in the aftermath of a disaster.
Validate: In interpersonal relations there are two types of validating. The first type is a process of testing if your assumptions are correct. If you make an assumption about what a person might be feeling or thinking, you should confirm your hunch. You can do this by saying, “You look worried to me. Are you?” or “If this happened to me, I would be thinking . . . . Is this what you are thinking?” The second type of validation is the act of acknowledging what another person is feeling. If what your child is feeling is obvious, you might say, for example, “I hear how sad you are,” or “You are angry.” You may use both of these types of validation to help your child.
Work: Freud’s definition of psychological health is the ability “to love and to work.” Work is basic to our emotional well-being. Unless it is not possible, you should set an example by continuing to go to work. Work does not only mean performing at a job. For example, you can also work on a home project with your child.
eXercise: Physical activity breaks the tension. Regular exercise promotes a “sound mind in a sound body,” because exercise benefits our brains as well as our bodies. Exercise is an activity that you and your child can do together.
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You: Yes, you! You are vital to your child’s well-being. Therefore, take care of yourself. Didn’t we say this already? Yes! We did. We said, “Care for yourself.” But, it is so important, we are saying it again. An important ingredient for good parenting is tolerating your emotional turmoil – especially anxiety – for the sake of your child. For example, you may have to tolerate being separated from your child while she is at school or an evacuation center during a disaster. Although being reunited with your child will relieve your anxiety, your child will become distressed upon seeing you in a severely agitated state. Therefore, it would better if you take some time and avoid rushing to her side until you get your own distress and aroused behavior under control.
Zebras: Zebras? Yes! Zebras! Think of Disney cartoons with appealing animals. How do they make you feel? Sometimes it helps to be silly, especially with younger children. It breaks the tension.
The physically disabled often will have special needs after a disaster. The devastation produced by the disaster may impede the mobility of an individual who was previously getting around his community. The need for services will vary according to an individual’s degree of disability. You may need to take a more active role to move a physically disabled person to safety, and to arrange for assistance. For someone who is homebound, you will need to make home visits. If an individual’s usual services are disrupted – for example, meals-on-wheels – you will need to arrange for an alternate way to supply his basic needs. Seek medical help when necessary. 179
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Accommodating the Physically Disabled
Facilities that have barriers should not be used for evacuation centers or shelters. Unfortunately, during emergency conditions, there may be no choice but to use such facilities. Therefore, you could be very helpful by assisting someone who is physically disabled and has been relocated to a facility with barriers. In addition, if an individual’s disability was caused by a previous trauma, the present disaster might trigger traumatic memories. Be mindful of his psychological state.
Caring for Seniors In a disaster, seniors have many basic needs and reactions similar to other populations. They also have strengths and weaknesses that make them both more resilient and yet more vulnerable. Their life experience has afforded them the gift of survival, and with that comes better coping abilities. However, frailty also comes with age, and this can bring on fatigue and despair. If you find yourself in a care-giving role to a senior, there are some simple ways to give assistance. The Four R’s for Assisting Seniors
Reaching out: Initiate contact, and do a safety check. Make sure the person is physically safe and has any necessary medications. Make the person comfortable and find out if she has sufficient food and shelter. Assist with the recovery of physical possessions. Arrange contact with family, medical back-up, caregiver, and/or a support facility.
Rapport: Establish rapport. Show concern and be gentle.
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Reassurance: Show support and confidence in the person’s ability to handle difficult situations. Let the person know that you will be there for him.
Referral: Refer the individual to appropriate special agencies for recovery of possessions, financial and emotional support, and other emergency assistance. [See Chapter 7 – “Seek Help” – for information about relief agencies, p. 132.]
Collaborating with People with Serious Mental Illness Work with the individual and her case manager at her community mental health center or with her private mental health professional as a preventive measure, even if there is no change in the individual’s condition, or she was not impacted directly by the disaster.
You can become a disaster victim emotionally just by helping disaster survivors, even if you were not directly impacted by the disaster. Just listening to a disaster victim’s tragic and horrible story may cause you distress. Stress can cause you to burn out. Therefore, taking care of yourself is essential while you help others. Below are tips on how you may care for yourself. [In addition, study Chapter 8 – “Help Yourself” – p. 141.] Know your limitations. Stay within your limits. Recognize when you are hearing information that is overwhelming to you. Pull back when things are becoming overwhelming. Recognize when you are getting “in over your head.” Pull back before you get “in over your head.” 181
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SELF-CARE WHILE YOU HELP OTHERS
Ask for help from your friends and relatives, when dealing with others in crisis. Use exercise and frequent breaks to relieve your own stress. Share your experiences as a helper by talking with others who are assisting disaster survivors. Accept that your reactions of stress, fatigue, or fearfulness are natural and valid. Seek professional help, if needed.
Donations for Disaster Relief and Recovery Do you know the best way to donate to help disaster victims? Chaos rules after a disaster. Getting the right supplies to the right place to help the right people is a logistical challenge. Your approach to offering donations has a critical impact on the lives of others. Under ordinary conditions, delivering materiel requires a well-organized system and an intact transportation network. However, disasters leave devastation in their wake. Roads may be washed out. Debris may block transportation routes. Bridges may no longer exist. Airport runways may be damaged and unusable. Communication networks may be destroyed. Delivery of donated goods, therefore, becomes problematic, if not impossible. If you donate goods, they need to be inspected, inventoried, and warehoused. Outdated, malfunctioning, or damaged items need to be discarded. Perishable items need to be refrigerated. You may donate shoes, but the need may be for coats; you may donate coats, but the victims may have no shoes. Donating goods can get in the way of disaster relief efforts. Donate goods only if specifically requested.
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It is much better for disaster relief organizations to receive donations of money. Money is easy to store. It doesn’t spoil. It can be wired across the globe to be used at appropriate locations nearest to the disaster. It can pay for supplies, as they are needed and in the quantities that are needed, after damage and needs assessments are done. It can be allocated for a variety of resources – water, food, clothing, bedding, medical supplies, shelter, construction materials, labor, etc. Money provides flexibility to address changing conditions.
Volunteering: Helpful or Dangerous? Do you know that numerous well-meaning individuals, who often are untrained, inexperienced, and/or unaffiliated with any disaster organization, show up at the scene of a disaster to lend a hand? There is an old saying that may well apply to the act of volunteering: “The road to Hell is filled with good intentions.” In response to 9/11, thousands of people volunteered for the first time to work with the American Red Cross. Other agencies were also flooded with new volunteers. Such individuals who just show up at the time of disaster are called “conver183
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You can arrange to make a donation by contacting one of the disaster relief organizations. You can go directly to an organization’s website, link to many organizations via the NVOAD website, or call an organization via its toll-free number. When there is a major disaster, newspapers list the disaster relief organizations that are seeking donations. You may wish to donate money periodically instead of doing so only when a major disaster occurs. These charitable organizations have ongoing needs and help countless victims of disasters which are not on a scale to merit widespread media coverage. [See – “Resource Directory”– in Chapter 7, p. 130.]
gent” volunteers (FEMA’s term) or “spontaneous” volunteers (the term used by the Red Cross). If you have ever been a convergent volunteer who has provided service, we applaud you for helping. Nevertheless, we prefer that compassionate and caring people become trained and affiliated volunteers. Training and affiliation better provide for the well-being of the volunteer, efficient emergency efforts, and most importantly, the maximum possible benefit for the victims. When people just show up at a disaster, they often become part of the problem instead of part of the solution. The individuals in charge of the emergency response or recovery efforts most likely do not know you. They do not know your background or what you are capable of doing. This is not the time for a job interview. The trained responders would rather focus their skills and energies on aiding the victims. They should not be spending time and effort on training convergent volunteers. Therefore, the quickest and most effective way of dealing with convergent volunteers is for police to bar them from the scene. If you are barred, your good intentions will be in vain, and your talents will be wasted. The solution to the convergent volunteer problem is preparedness. The best way to reduce the number of spontaneous volunteers is for you to join an organization today and be trained as soon as possible. Join the American Red Cross, The Salvation Army or any other disaster relief organization. Volunteer for your local Office of Emergency Management (OEM). Become a member of a volunteer ambulance corps or fire department. Join an OEM Community Emergency Response Team (CERT). These organizations will train you so that you can perform a vital role in disaster mitigation, preparedness, response, and recovery. 184
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DO 1 to 9
“All’s Well That Ends Well” William Shakespeare 1602-04
At the beginning, we stated that the 10 things that you should do are: l) determine the types and frequencies of the disasters that might happen, especially in your community, 2) learn what to expect when a disaster strikes, 3) prevent disasters or lessen their impact, 4) prepare for disasters, 5) learn the human reactions to disaster, 6) decide when you need to seek help, 7) find out where to get help, 8) help yourself, 9) help others, and 10) convince yourself that doing the first nine things are essential for your survival and the survival of others. We advise you to place into practice what you have learned from Chapters 1 through 9. In other words, implement the principles stated in each chapter title. In order to motivate yourself to do the other nine things, ask yourself, “Why do them?” Then, review the benefits. We have started a list for you, identifying the reasons why it makes sense to internalize the contents of this guide and to practice its principles and techniques. We encourage you to complete this list with some of your personal reasons.
Doing the 9 things is important because: Your survival may depend on it. The survival of your family, friends, or neighbors may depend on it. You can learn how to become a psychological survivor and not just a victim. You may strengthen your resilience. 185
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LIST OF REASONS
Your psychological well-being depends on knowing practical things to do. Knowledge is power. You will put the threats into perspective. Knowing what to expect can reduce the degree of traumatic stress and distress. “An ounce of prevention is worth a pound of cure.” Being prepared is vital. Planning is an important part of preparedness. Educating yourself is the pathway to knowledge. Practical things to do will be easily remembered in the heat of the moment. Rehearsing real life situations is the best way to learn and increase your skills. Knowing that your reactions are natural is reassuring. Distinguishing between natural reactions and disorders is essential. You need references to find valuable resources. Self-help is an element of resiliency. Knowing how to manage your fear helps you to react effectively, recover more rapidly, and regain self-confidence. Helping others can be fulfilling. If you are going to help others, you need to know how to do it. Learning the “ABC’s of Caring for Children” helps you care for your children Caring for your children helps them adjust and cope with adversity. Caring for individuals with special needs can be gratifying Self-care is necessary when you help others.
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Definition
What To Do
Mitigation
Mitigation means to make less (Latin, mitigare, to soften), hence to prevent injuries, death, property damage, and economic loss, or to minimize the severity of the impact of a disaster when these effects cannot be prevented.
Live safely. Practice safety in your home, at work, in school, while traveling, and in the use of electricity, hazardous materials (including combustibles), and firearms. Eliminate hazardous conditions. Be alert for potential disasters. Prevent the event from happening, or Reduce the impact of the event.
Preparedness Preparedness is the state of readiness. It consists of three tasks – planning, training and exercise.
Plan: Have an Emergency Plan, Disaster Supplies Kit, Evacuation Kit, First Aid Kit, and Vehicle Kit. Train: Educate yourself and teach others (for example, your family) what to do for each type of disaster. Learn First Aid and CPR. Exercise: Practice your emergency plan. Hold drills that include performing evacuation procedures.
Warning
Listen for disaster alerts. Follow directives from authorities. Warn others. Take pre-disaster action
Response
The actions that are taken from the time the disaster strikes to when the threat has ended.
Take action that is specific for type of disaster. Look for dangerous conditions. Maintain safety. Call for help (911). Rescue victims, if possible. Perform CPR, if trained. Administer first-aid, if trained. Help self and family and then neighbors. Monitor media broadcasts for updated information. Care for basic needs (clothing, food, shelter, water). Care for mental health. Receive immediate aid from disaster relief and government agencies.
Recovery
The process of returning to pre-disaster functioning and restoring the predisaster environment, or adapting to a new balance in functioning and a new way of living.
Assess the degree of damage and/or loss. Draw upon your strengths. Ask for ongoing support from disaster relief and government agencies. Obtain resources necessary for recovery. Repair damage. Care for general and mental health. Engage in mutual support with others. Learn from the experience to better mitigate, prepare, respond, and recover in the future (“lessons-learned”).
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Appendix
Things to Do for Any Disaster Phase
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West Nile Virus
Flu
AIDS
Disease
Symptoms
rapid weight loss dry cough, recurring fever or profuse night sweats profound and unexplained fatigue swollen lymph glands in the armpits, groin, or neck diarrhea that lasts for more than a week white spots or unusual blemishes on the tongue, in the mouth, or in the throat pneumonia red, brown, pink, or purplish blotches on or under the skin or inside the mouth, nose, or eyelids memory loss depression neurological symptoms
fever (usually high) headache fatigue (can be extreme) cough sore throat runny or stuffy nose body aches chills diarrhea and vomiting ( more common in children)
West Nile Fever: fever headache fatigue body aches (occasional) skin rash on the trunk of the body swollen lymph glands OR severe disease West Nile encephalitis, meningitis or poliomyelitis: headache high fever neck stiffness stupor disorientation coma tremors convulsions muscle weakness paralysis
Agent
human immuno-deficiency virus (HIV) Transmitted: sexual contact, bloodto-blood, and mother to child during birth and breast feeding
influenza viruses Transmitted: from person to person by coughing and sneezing or touching virus to mouth/nose
virus Transmitted: mosquito bite
Prevention: Use mosquito repellant. Mosquito proof your home. Treatment: only for symptoms
Prevention: Receive annual flu vaccine especially if in high risk group (chronic illness, weakened immune system, > 65 years old, children 6 to 23 months, caregivers of children < 6 months old, pregnant woman, age 6 months to 18 years on long-term aspirin therapy, nursing home residents and healthcare workers). Wash hands. Treatment: only for symptoms
Prevention: Practice responsible sexual behavior. Take precautions in high risk occupations. For example, healthcare workers should use gloves when in contact with patients, especially if using needles. Treatment: antiretroviral agents
Things to Do (Interventions)
Disease Outbreaks: Causative Agent, Transmission, Symptoms, and Things to Do
189 rapid
rapid
small dose: pupils dilate, runny nose, slight breathing difficulty moderate dose: same but greater breathing difficulty large dose: same plus loss of consciousness, seizures, paralysis and interruption of breathing
Nerve Gases
very rapid
small dose: mild cough, difficulty breathing, chest discomfort, burning eyes, nose and throat moderate dose: same plus eyes tear high dose: severe difficulty breathing, severe cough, wheezing
rapid breathing, headache, drowsiness, loss of consciousness, respiratory failure, cardiac arrest
Blood Agents
Interventions
Appendix
For Blister agents: Blot to remove, if in liquid form. Avoid rubbing skin.
Decontaminate: Remove clothing. Wash skin. Seek immediate emergency medical care.
slow (immediate to 2 For all: days) Move away from source if inhaled. Go to high place if inhaled. (Agents in gas form are heavier than air.)
Onset of Symptoms
Lung Toxins
fluid-filled skin blisters, itchy and burning skin, eye pain, respiratory tract irritation, pain, maybe nausea and vomiting
Symptoms
Things to Know for Chemical Terrorism
Blister Agents
Agent
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Viral Moderate Hemorrhagic Fevers
severe fever, fatigue, dizziness, muscle aches, loss of strength, exhaustion, bleeding under skin, internally, and from mouth, eyes, ears
–immediate vaccination –isolation and infection precautions
–antibiotics
–antibiotics within 24 hours of symptom onset (Use N95 mask near infected individuals.)
–antitoxin (Seek immediate emergency medical treatment.)
–antibiotics (Avoid moving around to limit spreading anthrax spores.)
Interventions
2-21 days; varies among –no established viruses treatment –isolation and infection precautions
averages 12-14 days but can range 7-17 days
High
Smallpox
initial: high fever, head and body aches, (sometimes) vomiting, skin rash beginning as small red spots, then becoming pustules (small, round bumps) that form crusts and scab, and fall off leaving scars
sudden fever, chills, headache, diarrhea, 3-5 days, but can be as muscle aches, joint pain, dry cough, progres- long as 14 days sive weakness; ulcer lesions of skin and mouth occur if direct contact; severe pneumonia, if inhaled
No
12-80 hours for inhalation
Tularemia
starts with dry mouth and muscle weakness of the head (double vision, droopy eyelids, difficulty speaking and swallowing), then paralysis of entire body; respiratory failure (death in 24-72 hours if untreated)
fever, headache, weakness, and rapidly devel- 1-6 days oping, severe pneumonia (chest pain, coughing up phlegm and blood, difficulty breathing)
No
Botulism
Onset of Symptoms
< 1 week; may be proflu-like [See table p. 156] but no runny nose, longed (up to 2 fever increases, severe breathing difficulty develops, skin becomes blue, then shock and months) coma
Symptoms
Things to Know for Bioterrorism
Pneumonic High Plague
No
Anthrax Inhalation
Agent
Person to Person Transmission
LEARN MORE ABOUT IT All Hazards Borofka, Michael. Emergency Survival Guide: You Can Survive Anything. Carmel, CA: Ventana Gear, 1994. Kelly, Kate. Living Safe in an Unsafe World: The Complete Guide to Family Preparedness. New York, NY: New American Library, 2000. Mason, Victoria. A Practical Guide to Survival: What to Do Before, During and After Disasters in the Home. MasonPublications, 1987. Piven, Joshua, and David Borgenicht. The Worst Case Scenario Survival Handbook. San Francisco, CA: Chronicle Books, 1999. Business Emergency Planning Childs, Donna and Stefan Pietrich. Contingency Planning and Disaster Recovery: A Small Business Guide. Hoboken, NJ: John Wiley & Sons, Inc., 2002. Mitroff, Ian. Why Some Companies Emerge Stronger and Better from a Crisis. New York, NY: American Management Association, 2005. Wallace, Michael and Webber, Lawrence. The Disaster Recovery Handbook: A Step-by-Step Plan to Ensure Business Continuity and Protect Vital Operations, Facilities, and Assets. New York, NY: AMACOM, 2004. Fear Management de Becker, Gavin. Fear Less: Real Truth about Risk, Safety, and Security in a Time of Terrorism. New York, NY: Little, Brown and Company, 2002. de Becker, Gavin. The Gift of Fear: Survival Signals That Protect Us from Violence. New York, NY: Little, Brown and Company, 2005, hardcover; New York: Dell Publishing, 1998, paperback. Food Preparedness Mason, Rosalie. Beginners Guide to Family Preparedness: Food Storage, Back to Basics, Survival Facts. Bountiful, UT: Horizon Publishers & Distributors, 1977. Spigarelli, Jack A. Crisis Preparedness Handbook: A Complete Guide to Home Storage and Physical Survival. Alpine, UT: Cross-Current Publishing, 2002. 191
Health and Healing Allen, Jon G. Coping With Trauma: Hope Through Understanding. 2nd Edition. Arlington, VA: American Psychiatric Publishing, Inc., 2005. Benson, Herbert, M.D. Timeless Healing: The Power and Biology of Belief. New York, NY: Simon & Schuster, 1997. Borysenko, Joan. Minding the Body, Mending the Mind. New York, NY: Bantam, 1993. Davis, Martha, Matthew McKay, and Patrick Fanning. Thoughts and Feelings: Taking Control of Your Moods and Your Life. Oakland, CA: New Harbinger Publications, Inc., 1997. Epstein, Robert. The Big Book of Stress Relief Games. New York, NY: McGraw-Hill, 2000. Frankl, Viktor E., M.D. Man's Search for Meaning. New York, NY: Pocket Books, 1984. Mc Williams, Mary Beth. The PTSD Workbook: Simple, Effective Techniques for Overcoming Traumatic Stress Symptoms. Oakland, CA: New Harbinger Publications, Inc., 2002. Mc Williams, Peter. You Can’t Afford the Luxury of a Negative Thought. Los Angeles, CA: Prelude Press, 1995. Rush-Presbyterian-St. Luke's Medical Center. Medical Encyclopedia. Chicago, IL: World Book, Inc., 1991. Seligman, Martin E.P., Ph.D. Learned Optimism. New York, NY: Simon & Schuster, 1990. Simon, William H., George E. Ehrlich, and Arnold Sadwin (eds). Conquering Chronic Pain After Injury: An Integrative Approach to Treating Post-Traumatic Pain. New York: Avery/Penguin Putnam Inc., 2002. Natural Disasters Junchaya, Kellye A. They Laughed at Noah: Preparing for Natural Disasters. Clifton, NJ: Medcap, 1999. Nwanna, Gladson I. Natural Disasters and Other Emergencies, What You Should Know: A Family Planning and Survival Guide. Somerville, MA: Frontline Publishers, 2004. Ropeik, David and George Gray. Risk: A Practical Guide for Deciding What’s Really Safe and What’s Really Dangerous in the World Around You. New York, NY: Houghton Mifflin Company, 2002. Resiliency Bridges, William. The Way of Transition: Embracing Life’s Most Difficult Moments. Philadelphia, PA: Perseus Publishing, 2001. 192
Brooks, Robert and Sam Goldstein. The Power of Resilience: Achieving Balance, Confident and Personal Strength in Your Life. New York, NY: McGraw-Hill, 2003. Flach, Frederic. Resilience: Discovering a New Strength in Times of Stress. Long Island City, NY: Hatherleigh Press, 2002. Shatte, Andrew and Karen Reivich. The Resilience Factor: 7 Essential Skills for Overcoming Life’s Inevitable Obstacles. New York, NY: Broadway, 2002. Risk Assessment Lee, Laura. 100 Most Dangerous Things in Everyday Life and What You Can Do About Them. New York, NY: Broadway Books, 2004. Safety and Security Aviv, Juval. The Complete Terrorism Survival Guide: How to Travel, Work and Live in Safety. Huntington, NY: Juris Publishing, Inc., 2003. Glover, Jim. Street Smarts, Firearms, and Personal Security: Jim Glover’s Guide to Staying Alive and Avoiding Crime in the Real World. Boulder, CO: Paladin Press, 2000. Kehayan, V. Alex and Tindall, Judith. Bicycle Safety Peer Program. Gladstone, MO: National Association of Peer Programs, 2004. Rawls, Neal and Sue Kovach. Be Alert, Be Aware, Have a Plan: the Complete Guide to Personal Security. Guilford, CT: Globe Pequot Press, 2002. Terrorism Acquista, Angelo. The Survival Guide: What to Do in a Biological, Chemical, or Nuclear Emergency. New York, NY: Random House Trade Paperbacks, 2003. Beahm, George W. Straight Talk About Terrorism: Protecting Your Home and Family from Nuclear, Biological, and Chemical Attacks. Dulles, VA: Brassey’s, Inc., 2003. Volunteers Canfield, Jack, Mark Hansen, Arline Oberst, John Boal, and Tom Lagana. Chicken Soup for the Volunteer’s Soul. Deerfield Beach, FL: Health Communications, 2002.
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ACKNOWLEDGMENTS We gratefully acknowledge our debt to those who have preceded us in the fields of disaster mental health and emergency management, and to our colleagues currently contributing to the understanding and care of the survivors of disasters. In emergency management, a basic principle is “do not reinvent the wheel.” We have demonstrated our acceptance of this principle by not only giving you the benefit of our experience and knowledge, but also bringing together in this handy guide the collective wisdom of many other disaster survival experts. We applaud all emergency responders and disaster relief workers for their dedication and sacrifices. We give tribute to those who responded to the terrorist attacks on September 11, 2001. We especially thank the emergency responders and disaster mental health workers with whom we personally trained and worked and who have taught us so much. We thank the members of the Fort Lee, NJ Community Crisis Response Team, the Crisis Response Team of the Fort Lee Office of Emergency Management, the Crisis Counselor Team of Englewood Hospital and Medical Center in Englewood, NJ, the Disaster Preparedness Committee and the Disaster Response Network of the New Jersey Psychiatric Association, the New Jersey Disaster Mental Health Services of the American Red Cross, and the New Jersey Emergency Management Association. To all those on whom we have relied to help us make this an informative book that addresses people’s concerns in the face of disaster and terrorism, we are indebted. We acknowledge the helpful insights of our informal focus groups for our cover design – the gang at Breaking News Network (Rob and Steve Gessmann and their staff - Chris Casale and Brian Duddy) Dr. Napoli’s colleagues at Englewood Hospital and Medical Center (Drs. Chertoff, Freidman, Ciora, Schumeister and Phylliss Capiaghi, RN, Gail Lundy RN, and Craig Hilton, MSW) and our families. We are also grateful for the views and advice of Michael Bartolomei, Joe Bruncati, David Duncan, Bob and Debbie Doerig, Ross Fieldson, Richard Formica, Nicholas Gee, Dr. Ray Handbury, 194
Mark Hatton, Dr. Jill Kedersha McClay, Ann Martini, Dr. Fran Michaels, Joseph Mitchell, Andrew Pollock, Dr. Jakob Steinberg, Kevin Stroh, Michael Stroh, Dr. Judy Tindall, Dr. Margaret Tompsett, Rev. Jim Warnke, and Dr. Peter Wolf. We thank Randall Marshall, M.D. and Stuart Weiss, M.D. for reviewing aspects of our book, checking our accuracy and providing their expert advice. We are grateful to our reviewers – Diana Brown, Joe Licata and Dr. Barbara Varenhorst for their generous praise. We especially thank our outstanding editor Loretta Napoli for constantly challenging our thoughts and for working so hard on this project. We thank our wonderful publishers Bradley and Cathy Winch of Personhood Press, who collaborated with us every step of the way to bring our book to press, Peter Forster, who imparted his savvy business advice, Christine Scharch of Tupelo Art, our talented graphic designer who is a delight to work with, and Erin Scanlon, our indispensable and efficient research assistant. Most importantly we are grateful to our respective families for their love, support and advice – Alex’s wife, Carolyn, and son, Cary, and Joe’s wife, Loretta, daughters, Gina and Laura, and son-in-law, Nick.
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ABOUT THE AUTHORS Drs. Kehayan and Napoli, Co-Directors of Resiliency LLC, a partnership for crisis and disaster consultation and training, have collaborated for many years in the fields of disaster mental health and emergency management. They have designed and taught courses on disaster mental health for various audiences including mental health professionals and peer leaders. They have participated in the planning and execution of numerous disaster exercises. Individually, they have responded to many crises and disasters. Together, most notably as volunteer Fort Lee Office of Emergency Management crisis counselors, they aided employees of the Port Authority of New York and New Jersey, and officers of the Port Authority Police Department in the aftermath of 9/11.
V. Alex Kehayan, Ed.D. Author of three other books: SAGE, Partners for Change, and Peer-Led Bicycle Safety Program Co-Founder of the Community Crisis Response Team of Fort Lee, NJ Director of Edu-Psych, Inc., a training and consultation network, Ridgewood, NJ National Association of Peer Programs Scholar of the Year Award for his lifetime achievements Private practice specializing in anxiety, Ridgewood, NJ Joseph C. Napoli, M.D., DFAPA American Psychiatric Association Bruno Lima Award for his outstanding contributions to the care and understanding of the victims of disaster Assistant Clinical Professor of Psychiatry, College of Physicians and Surgeons of Columbia University Chairperson, Disaster Preparedness Committee, New Jersey Psychiatric Association Distinguished Fellow, American Psychiatric Association Former volunteer firefighter Private practice specializing in posttraumatic stress disorders, Fort Lee, NJ
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