Disaster health

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Instructions

This section provides a summary of the area of practice for this unit and highlights the importance of this topic to general practice and the role of the GP.

Disasters are increasing in frequency, in severity, and in the number of people affected. Climate change and climate-related disasters are major contributors to this observed increase.1 In recent years, Australia has experienced a number of formidable disasters including the 2019–20 Black Summer bushfires and the COVID-19 pandemic, alongside a number of smaller but also devastating bushfires, floods, cyclones and storms. Since January 2019, Disaster Assist acknowledges 100 different disasters in Australia for which they are offering support for multiple affected communities.

Disasters can affect humans in multiple ways including socially, physically, mentally and economically. Disasters impact the social determinants of health, including employment status, housing, access to healthcare, and food insecurity, leading to poor long-term outcomes.2,3 Studies are beginning to explore the relationship between disaster occurrence and socio-economic disadvantage.4 No Australian community is exempt from the risk of disaster whether defined by geographic location or by cultural characteristics: metro/urban, regional, rural and remote locations, Aboriginal and Torres Strait Islander communities, and culturally and linguistically diverse communities.

Health effects of disasters can occur over the immediate, short and long-term and can lead to acute and chronic physical and mental impacts.5 Typical acute disaster-related presentations include burns, smoke and dehydration.5 Disasters are also linked to preterm births, poor control of established conditions such as diabetes, delayed diagnosis of other new medical conditions, increased deaths in the elderly population and long-term psychological impacts.5 Disasters can also have indirect impacts, including damage to health infrastructure, loss of access to healthcare and dislocation between patients and their regular healthcare provider, which causes gaps in continuity of care.5

General practitioners (GPs) manage the bulk of usual healthcare in a community in inter-disaster periods. This healthcare burden does not disappear when disasters occur and research shows the major burden of care in disasters falls within the realm of general practice.6,7 GPs are essential during crisis and the value and relevance of primary care in disasters is acknowledged by many, including the World Health
References
  1. Centre for Research on the Epidemiology of Disasters and UN Office for Disaster Risk Reduction. Human cost of disasters: An overview of the last 20 years – 2000-2019. Geneva and Brussels: CRED and UNDRR, 2020.
  2. Jiao Z, Kakoulides SV, Moscona J, et al. 2012. Effect of Hurricane Katrina on incidence of acute myocardial infarction in New Orleans three years after the storm. Am J Cardiol 2011;109(4):502–05.
  3. Greenough PG, Lappi MD, Hsu E B, et al. Burden of disease and health status among Hurricane Katrina-displaced persons in shelters: A population-based cluster sample. Ann Emerg Med 2008;51(4):426–32.
  4. Sewell T, Stephens R, Dominey-Howes D, Bruce E, Perkins-Kirkpatrick S. Disaster declarations associated with bushfires, floods and storms in New South Wales, Australia between 2004 and 2014. Scientific Reports 2016;6:1–11.
  5. Commonwealth of Australia, Department of the Prime Minister and Cabinet. A national approach to national disaster: The Commonwealth Government response to the Royal Commision into National Natural Disaster Arrangements. Barton ACT: Commonwealth of Australia, 2020.
  6. Kohsaka S, Endo Y, Ueda I, Namiki J, Fukuda K. 2012. Necessity for primary care immediately after the March 11 tsunami and earthquake in Japan. Arch Intern Med 2021;172(3): 290–91.
  7. World Health Organisation. Primary health care and health emergencies: Brief. Geneva: WHO, 2018.
  8. Commonwealth of Australia. Royal Commission into National Natural Disaster Arrangements Report. Canberra: Commonwealth of Australia, 2020.
  9. Burns P, Manderson K. Building GP capacity in times of disaster. MJA InSight+ 2020;3 [Accessed 7 September 2021].
  10. Burns P, Douglas K, Hu W, Aitken P, Raphael B. General practitioners in the field: A qualitative study of general practitioners' experiences in disaster healthcare. Aust J Gen Pract 2020;49(3):132–38.
  11. World Medical Association. WMA Statement on Medical Ethics in the Event of Disasters. Chicago, USA: WMA 2017 [Accessed 7 September 2021].
  12. FitzGerald GJ, Aitken P, Arbon P, et al. A National framework for disaster health education in Australia. Prehosp Disaster Med 2010;25(1):4–11. doi: 10.1017/s1049023x00007585.

Instructions

This section lists the knowledge, skills and attitudes that are expected of a GP for this contextual unit. These are expressed as measurable learning outcomes, listed in the left column. These learning outcomes align to the core competency outcomes of the seven core units, which are listed in the column on the right.

Communication and the patient–doctor relationship
Learning outcomes Related core competency outcomes
The GP is able to:   
  • demonstrate appropriate respect and concern for patients, families and communities who have experienced disasters in a trauma-informed and culturally safe manner appropriate to the patients’ context
1.1.2, 1.2.1, 1.2.2, 1.2.3, 1.3.1, 1.3.2, AH1.3.1, RH1.1.1
  • demonstrate knowledge of appropriate communication with other health professionals and emergency services in disaster situations
RH1.1.1
  • communicate with other health professionals and emergency services in a coordinated, clear and timely manner
RH1.1.1
Applied knowledge and skills
Learning outcomes Related core competency outcomes
The GP is able to:   
  • evaluate situations where Psychological First Aid and Skills for Psychological Recovery would be appropriate and demonstrate competence in their provision
2.1.3, 2.3.1
  • discuss disaster triage, sieve and sort, with an understanding of where it fits within the structured response of major incident medical management and support (MIMMS) systems
2.1.3, 2.3.1
  • critically appraise competing information sources in disasters and pandemics targeting several sources of truth for reference during the changing environment and changing clinical recommendations
2.2.1, 2.2.2
  • discuss how GPs can demonstrate leadership in emergency or disaster situations across the range of hazards most likely in the local practice region
2.3.3
  • collaborate with other health and emergency services on patient care during and after disasters to provide overall coordination of patient care, minimise fragmentation of care, and contribute to patient management during surges across the whole health system
2.3.3, 2.3.2, 2.3.1, AH2.3.1, AH2.3.2, RH2.3.1
  • adapt and innovate clinical care during the difficult environment of disasters and pandemics, working within disaster and pandemic management systems informed by evidence and best practice
2.3.1, 2.3.2, 2.3.3, 2.3.4
  • summarise the key concepts of disaster management and how GPs contribute through each stage of disaster: Prevention, Preparedness, Response and Recovery
2.2.2, 2.3.1, 2.3.2, 2.3.3, 2.3.4, RH2.3.1, AH2.1.2, AH2.3.1
Population health and the context of general practice
Learning outcomes Related core competency outcomes
The GP is able to:   
  • explain factors affecting each individual and each community’s vulnerability and resilience to optimise disaster healthcare and surveillance during the acute and post-disaster periods
3.2.1, 3.2.3, AH3.2.1, AH3.2.2
  • discuss the risk to local population health and deterioration of social determinants of health and consider the potential for change in chronobiology of clinical conditions
3.1.1, 3.1.3, 3.2.3, AH3.2.2
  • evaluate the additional impact of disasters and pandemics on communities, including rural, culturally and linguistically diverse, Aboriginal and Torres Strait Islander, and socially disadvantaged, and discuss mitigation strategies  
AH3.2.2, 3.1.3
  • explain the risk factors and epidemiological pattern of psychological and physical health conditions likely to occur during the disaster and in the weeks, months and years following, to enable early identification and management, including screening and active case finding
3.1.1, 3.1.3, 3.2.1, 3.2.3, AH3.2.1, AH3.2.2
  • formulate media strategies to provide updated health information to the local community in a disaster, or to limit exposure of self or others to the media, as appropriate
RH3.1.1, 3.1.3, 3.2.2
Professional and ethical role
Learning outcomes Related core competency outcomes
The GP is able to:   
  • institute and maintain self-care strategies and avenues for support prior to any local community disaster when GPs often play a strong role in caring for disaster-affected patients
4.2.1, RH4.2
  • maintain self-awareness of the effects of disasters on GPs and practice staff in their dual roles as local community members and local health professionals, while taking into account strengths, vulnerabilities, personal characteristics and disaster exposure.
RH4.2.1, 4.3.3
  • appraise the risk of infection transmission in different scenarios and demonstrate donning and doffing of full personal protective equipment, including fit-checking
4.1.1
Organisational and legal dimensions
Learning outcomes Related core competency outcomes
The GP is able to:   
  • discuss the principles involved in business continuity and disaster planning for the general practice, including for a pandemic
5.1.1, 5.1.2, RH5.1.1
  • discuss how to provide a practice environment that is culturally and psychologically safe for disaster-affected community members and for practice staff, including GPs themselves
5.2.5, 5.2.6
  • ensure that appropriate practice procedures and processes are in place for monitoring and ongoing review of patients at higher risk of adverse effects on psychological health, physical health, or social determinants of health
AH5.1.1, AH5.1.2, AH5.2.1
  • assess risk of transmission of infection during an infectious disease outbreak and apply the hierarchy of controls and principles of infection prevention and control to a standard general practice setting
5.1.1, AH5.1.1

Instructions

This section includes tips related to this unit from experienced GPs. This list is in no way exhaustive but gives you tips to consider applying to your practice.

Extension exercise: Speak to your study group or colleagues to see if they have further tips to add to the list.

  1. Disasters have catastrophic effects on humans. When disaster strikes a community the local GP will inevitably be involved. It is vital to consider your role as a GP before disaster occurs.
  2. There are several ways to begin to understand disasters:
    • through a scenario, guided by someone knowledgeable in the field, such as your supervisor or the local hospital disaster manager
    • by taking part in a local health district disaster exercise
    • by listening to someone who has been through a disaster – either professionally or as a personal experience.
  3. Disaster planning doesn’t need to be complicated. It’s valuable to simply run through your disaster plan in your mind or create a one-page plan.
  4. Recovery and resilience begins in good planning and preparedness, including self-care – it is easy to forget to look after your own safety and wellbeing. Remember that you don’t need to do everything yourself. The best disaster professionals monitor their own alertness levels and know when to remove themselves from the disaster response until they feel safe to return to continue to assist. This helps them stay safe and be able to continue to provide support to their community.
  5. During a pandemic, universal collaboration is crucial for successful management: at the local, national and global levels. You can't fight a pandemic on your own.

Instructions

  1. Read this example of a common case consultation for this unit in general practice.
  2. Thinking about the case example, reflect on and answer the questions in the table below.

You can do this either on your own or with a study partner or supervisor.

The questions in the table below are ordered according to the RACGP clinical exam assessment areas and domains, to prompt you to think about different aspects of the case example.

Note that these are examples only of questions that may be asked in your assessments.

Extension exercise: Create your own questions or develop a new case to further your learning.

Disaster health

You are one of four GPs working in a small remote community where a prolonged heatwave has been followed by high winds and catastrophic fires in the nearby national park. Several lives have been lost; no one knows who is safe and who is missing. Many locals have been evacuated. Smoke is blanketing the town. Most of the town is without power. Your family, home and property are safe.

Peter, a 38-year-old local farmer with hypertension, diabetes and asthma presents asking for scripts for his usual medications. ‘My meds got burnt in the fire, along with my house, my best stud Murray Grey, and most of my feed. I’m not sleeping so well, Doc. I’m having trouble focusing, and getting a bit irritable with the kids. The boys are four and eight years old. They’ve both gone really quiet which is pretty unusual for them, but that’s normal after a big bushfire, isn’t it? I guess it’s good because we’re all staying at the in-laws, and it’s very crowded.’

Questions for you to consider Clinical exam assessment area Domains

How would you approach this consultation in a trauma-informed manner?

How could you empower Peter using Skills for Psychological Recovery (SPR)?

  1. Communication and consultation skills
1,2,5

What are your priorities in history-taking and clinical examination? Why? How does the disaster context broaden and reprioritise the information you need to gather?

What more would you like to know about Peter’s children and their significant change in behaviour? Is it concerning?

What factors in Peter’s environment support or undermine his resilience?

  1. Clinical information gathering and interpretation
2   

During this acute phase of the disaster what are the key social, mental and physical health needs to consider for Peter and his family?

  1. Making a diagnosis, decision making and reasoning
2   

What is your approach to managing Peter and his family? What resources could help you?

  1. Clinical management and therapeutic reasoning
2   

How might you identify people needing extra support in your local community? Which organisations could you partner with in your community to provide that support?

  1. Preventive and population health     
1,2,3

A GP is often involved in a disaster as both a professional and a member of the community. The time to develop self-care strategies is before a disaster occurs. What strategies could you use for yourself, your family and your practice?

  1. Professionalism
4   

What is the role of a GP in each of the four phases of disaster? Which of the four phases applies to this case example?

Does your practice have a disaster plan? A pandemic plan? Can you draft a one-page version of either? (See learning resources section for more information.)

  1. General practice systems and regulatory requirement
5   

What if Peter’s wife arrives during the consultation and insists on joining? She is obviously distressed and unable to focus. Can you demonstrate how you would provide Psychological First Aid (PFA)?

Can you demonstrate donning and doffing full personal protective equipment (PPE) including fit-checking a P2 or N95 mask?

  1. Procedural skills
2   

Situations rapidly evolve during disasters and that means guidelines change too. How can you stay up to date with the latest accurate information? 

What if you receive a phone call notifying you that the local aged care facility is being evacuated and relocated into the community hall as all roads out of the town are closed due to fire? About 40 patients will be arriving with access only to nursing staff. What would you do? How would you adapt and innovate to provide good medical care?

  1. Managing uncertainty
2   

How would you safety-net Peter, considering his chronic conditions?

  1. Identifying and managing the significantly ill patient
2

Instructions

This section has some suggestions for how you can learn this unit. These learning suggestions will help you apply your knowledge to your clinical practice and build your skills and confidence in all of the broader competencies required of a GP.

There are suggestions for activities to do:

  • on your own
  • with a supervisor or other colleague
  • in a small group
  • with a non-medical person, such as a friend or family member.

Within each learning strategy is a hint about how to self-evaluate your learning in this core unit.

On your own

Read this story of a GP affected by the 2009 Victorian bushfires.

  • Consider his experience. Does this give you some ideas for self-care if you find yourself involved in a disaster?

Watch Nicola Palfry’s explanation of trauma-informed care.

  • Consider a patient you may have seen recently who was ‘behaving poorly’. Does the video change your approach to such patients? In what ways?

Complete one of these units in the Emerging Minds Community Trauma Toolkit for GPs that discusses how GPs can support children during disasters.

For children aged 0–5 years
For children aged 6–8 years  
  • Consider the two children of the patient in the case consultation example above. Is their change in behaviour concerning? What more would you want to know about them? How would you support their parent/s to support their children?
With a supervisor

Run through your practice’s pandemic scenario with your supervisor, and then answer the following questions. You may like to refer to Managing pandemic influenza in general practice.

  • Does your practice have a plan? What is the plan? What would your role be? How would you manage patient flow? How would you manage staff? What about managing infection prevention and control?

Following a disaster, a GP practice can be very busy; there may be many distressed patients presenting, and even police seeking information on the missing or deceased. Consider how you would manage your practice and support staff.

  • How could you manage the distress in the waiting room and prepare and support your front desk staff, as well as the rest of your GP team?
  • Ask your supervisor about any experience of disaster situations they have had and what they learnt from them.

Discuss being a rural GP in a disaster-affected area. Consider one of your usual patients who presents during the disaster, then at 1 week, 3 months and 6 months later.

Children are particularly vulnerable in disasters. They may present with behavioural changes in the immediate aftermath of a disaster; for example, an adolescent needing to sleep with their parents, or a normally active child becoming withdrawn and quiet. Discuss with your supervisor the different psychological and physical vulnerabilities of children in disaster.

  • How would you help parents to support their children through these difficult times? What resources could you direct them to?
  • Does your supervisor have any suggestions?
  • See the learning resources section for more ideas.
In a small group

Read Psychological First Aid: An Australian guide to supporting people affected by disaster. Then consider this disaster scenario: Immediately following a cyclone you are assisting at an evacuation centre where a woman and young boy are sitting alone in a corner. You go over and they appear to be physically unharmed but in shock. Discuss or role-play the scenario with your group.

  • Consider how you would manage this situation, including the use of Psychological First Aid (PFA).
  • If you are watching the role play, make notes on what principles are being applied in this situation.
  • Give feedback to each other.

Discuss a pandemic scenario: There has been an outbreak of a new influenza virus and it has just arrived in your local community. Two cases have been identified in a neighbouring practice which has now shut for two weeks. Hold a meeting to discuss your practice’s pandemic plan in this situation.

  • What would you do to reorganise your usual business to keep yourself, staff and patients safe?
  • What are your main aims at this early stage?
  • Discuss how you might support patients from the other practice.
  • How might you manage your infection prevention and control processes? Refer to the RACGP Pandemic flu kit.
With a friend or family member

Discuss your family’s disaster plan with them or develop one together; keep it to one page. Brainstorm what it should include.

  • Was it hard to keep it to one page? What are the priorities?
  • Who is best placed to be responsible for which items?
  • Did you include your pets, if you have any?

Talk to your family, friends or patients about how the COVID-19 pandemic affected them.

  • What did you learn that surprised you? How can this help you with your clinical practice?

Instructions

These are examples of topic areas for this unit that can be used to help guide your study.

Note that this is not a complete or exhaustive list, but rather a starting point for your learning.

  • Understand population health and the context of general practice:
    • Key concepts of disaster management:
      • all hazards
      • all agencies
      • prevention, preparedness, response, recovery (PPRR).
    • The changing roles of GPs in natural and man-made disasters through each phase of PPRR.
    • Business continuity planning for the general practice during disasters and pandemics.
    • Adaptation of practice procedures and processes to accommodate changing healthcare needs during disasters and pandemics.
  • Understand pandemics:
    • How pandemics occur and evolve.
    • The aims and strategies of pandemic management; including public health measures and governance systems.
    • The changing roles of GPs through the phases of a pandemic: prevention, preparedness, response and recovery.
  • Understand the health consequences of disasters:
    • The variations in health consequences across and within various hazards.
    • The risk factors for, and epidemiological patterns of, psychological and physical health conditions likely to occur during the disaster and in the weeks, months and years following, to enable early identification and management; including screening and active case-finding.
    • The risk to local population health and deterioration of social determinants of health, and the potential for change in chronobiology of clinical conditions.
  • Consider resilience and vulnerability:
    • Understand contributing factors so as to optimise disaster healthcare and surveillance during the acute and post-disaster periods.
    • Understand the different impacts of disasters and pandemics on different populations: rural, culturally and linguistically diverse people, Aboriginal and Torres Strait Islander peoples, socially disadvantaged communities, children, pregnant and breast-feeding women, the elderly and those with chronic disease; consider mitigation strategies.
  • Understand principles of self-care for GPs and practice staff.
  • Be competent in:
    • trauma-informed care
    • Psychological First Aid (PFA) and Skills for Psychological Recovery (SPR)
    • donning and doffing of full personal protective equipment (PPE); including fit-checking.
  • Understand disaster triage sieve and sort within a structured response to disaster.
  • Manage media and the flow of information:
    • Critically appraise competing information sources in disasters and pandemics, identifying several sources of truth for reference regarding the changing environment and changing clinical recommendations.
    • Understand when it is appropriate and safe to provide updated health information to the local community in a disaster.

Instructions

The following list of resources is provided as a starting point to help guide your learning only and is not an exhaustive list of all resources. It is your responsibility as an independent learner to identify further resources suited to your learning needs, and to ensure that you refer to the most up-to-date guidelines on a particular topic area, noting that any assessments will utilise current guidelines.

Journal articles
The roles of GPs across the four stages of disasters; Figure 1 provides an overview of the GP healthcare response. Provides a pandemic response in Australian Aboriginal and Torres Strait Islander communities.
Textbooks
Disaster medicine is covered in the emergency medicine chapter and explains the basics of disaster management for GPs.  
Online resources
Provides a broad overview of emergencies in general practice and includes a section on self-care. A basic discussion on pandemics and the implementation in general practice. A guide to Psychological First Aid. A guide to Skills for Psychological Recovery. This toolkit focuses on children in disasters, including the effects on children at different stages of the disaster, and the different needs according to age, stage or context, such as rurality. This post-natural disaster health pathway has particularly helpful guidance on managing patients. A guide for emergency services relating to the needs of those with diabetes and other chronic conditions. An outline of the concept of trauma-informed care and useful links to resources and further education.
Learning activities
Providing psychological support, including Psychological First Aid and Skills for Psychological Recovery.
  • The Royal Australian College of General Practitioners. gplearning:
    • Disaster recovery – providing psychological support

Excellent training on the basics of disaster response at the scene of an incident, including disaster triage.

Other
  • RACGP Specific Interest groups:
    • Disaster management
    • Child and young person’s health
    • Climate and environmental medicine
This contextual unit relates to the other unit/s of:
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Printed from the RACGP website at https://www.racgp.org.au/education/education-providers/curriculum/curriculum-and-syllabus/units/disaster-health 28/06/2022