Out of the comfort zone: EMS in the wake of a natural disaster

Responding to the medical needs of the 2015 Nepal earthquake survivors pushed a Calif. medic out her comfort zone as she strived to make a difference


Paramedic Julie Beach spent 10 days with the American Nepali Medical Foundation in Nepal after the 2015 earthquake. In this article, Beach, with help from EMS1 columnist Patrick Lickiss, shares entries from her journal written during and after her time in Nepal with information on how EMS providers can prepare for domestic or international disaster response. 

By Julie Beach and Patrick Lickiss

On April 25, 2015 at 11:56 local time in an area approximately 80 km northwest of Kathmandu, a 7.8 magnitude earthquake struck the country of Nepal lasting nearly a minute and shifting the capital city 10 feet to the south of its original location [1, 2].

Most Nepali live in unreinforced masonry buildings which have a higher risk of collapse during an earthquake. This event was no exception. The earthquake triggered avalanches on Mount Everest and in the Langtang Valley.

Paramedic Julie Beach, wearing a yellow face scarf, cares for a patient in a field hospital after the Nepal earthquake. (Photo courtesy of Julie Beach)
Paramedic Julie Beach, wearing a yellow face scarf, cares for a patient in a field hospital after the Nepal earthquake. (Photo courtesy of Julie Beach)

In total, 8,962 people were killed and 22,302 were injured [3]. Damage estimates totaled $10 billion, representing half of Nepal’s gross domestic product [4]. With already limited financial and infrastructure resources, the 2015 earthquake was catastrophic for the people of Nepal.

Going to help: April 29, 2015
I put in an interest card via a girlfriend’s Facebook link. I didn't think I'd actually get picked up.

What the hell am I doing?

I’m going to help. That’s what I do, and that is what I’m going to do. I am excited and incredibly nervous.

A two-week leave has been approved from work and I am leaving for Kathmandu, Nepal in the morning as part of an emergency medical response and relief team to assist in caring for the victims of a 7.8 earthquake. The country is devastated.

There is a huge part of me that wants to read everything I can to prepare, but the other half is worried that I’m going to psych myself out of this opportunity if I do. I have to go into this with an open heart and clear mind.

I need to be ready for anything.

Breaking from normal: April 30, 2015
The first team member I meet is a neurology nurse and the one that helped coordinate this response. We meet at San Francisco Airport just as our plane is arriving. We have to sprint to the gate, large back packs and sleeping bags in tow.

This entire experience seems surreal so far. Finding myself on an international flight with less than 24 hour notice is just a bit off of my normal routine.  

Logistics of travel
When considering working overseas in a disaster response capacity, providers must keep in mind that simply getting to a location is a monumental task in itself. Logistics of travel to and around an affected country should be at the top of your mind.

If you don’t already have a passport, attempting to obtain one in time to help out in the initial disaster response is likely not possible. Even paying additional fees for expedited processing, expect at least two to three weeks to obtain your passport. While it is technically possible to obtain a passport in eight business days, it requires that you be in close proximity to a passport office. If you think you may have an interest in international medical response, keep your passport current.

Depending on the extent of damage in the country to which you are responding, you will need to determine how best to travel to the country. If local airports have been seriously damaged it may not be possible to fly directly to the country where the disaster has occurred. Lining up ground or water transportation in a country you have never been to during a natural or manmade disaster is not a recipe for success.

Avoid becoming part of the problem by joining a recognized medical organization or governmental response team. Doing so will allow many of the travel logistics tasks to be handled by experts and will ultimately keep you safe and able to accomplish your goal on the ground. Find and join an organization now, before the next disaster, to gain skills and experience for a future deployment.

I went to Nepal as volunteer with the American Nepal Medical Foundation. ANMF is a United States-based non-profit membership organization which focuses on stabilizing, researching and advancing medical care in Nepal.

Since recognized organizations and governmental teams are often responding at the request of the local government, many of the concerns about licensure can be dealt with in advance on your behalf. Freelancing and showing up in a disaster may seem like a romantic idea, but is never recommended. Instead, become involved with your local urban search and rescue team or disaster medical assistance team.

Reality on the ground: May 2, 2015

The reality of the situation hits me. We have a lot of work ahead of us.

Our five person team is now together. In addition to the nurse, the team consists of a cardiologist, nephrologist and a nurse practitioner. We’ll be leaving Kathmandu tomorrow for Nuwakot, one of the worst affected areas. Their hospital has been destroyed by the earthquake. We’ll be working in a makeshift ER/ICU outside of the hospital.

I have been advised that death toll exceeds 7,000 at this point. There are also over 15,000 injured.

Providing care
Being open and honest with yourself about what you can do to help in a disaster response is an important component of committing to responding. In all likelihood, your role will be far different from your daily practice in domestic EMS and might not fully meet your expectations. Supplies will be limited and scope of practice may be broad. In a disaster, like in any triage situation, many critically injured patients will not survive to definitive care and those that do take up huge amounts of resources from patients more likely to survive.

Very often, your role will be largely clinic-based. Rounding with physicians and providing follow-up care for sick and injured patients will take a large part of your time. There may be opportunities to put ALS skills to work but the focus in these clinic settings is mostly BLS.

Many non-governmental organizations that respond to foreign disasters develop their own supply chain for equipment and medications since a given country may not have ready access to supplies in the best of circumstances. While that is the case, these NGOs are often limited in what they do have available so responders should be prepared to substitute equipment and medications and must be flexible when deciding on a course of treatment.

Limited resources and tough choices: May 4, 2015
We have arrived in Nuwakot. Bhutan’s military has set up tents and is managing medical care around the area of the former hospital. They have agreed to allow us to assist in care. The hospital itself is structurally unsafe and unusable with the exception of one OR that is still intact.

Our team is led to an area of tents that is serving as a makeshift ICU/ER. There are rows of patients on cots, some on the ground on mats. I notice one with a chest tube, many patients with open and infected wounds and a small girl in the corner with an open tib/fib fracture.

The entire scene is absolutely unbelievable and so vastly different from anything I have ever seen in the U.S. There are no nurses here at this time, just students and doctors of various disciplines. There just aren’t enough resources available.

There's a woman with an unstable pelvic fracture that the nursing student tells me was near full term in her pregnancy. She was buried in rubble from the waist down during the earthquake. She went into labor. The baby didn’t make it.

She was brought here by family and they’ve done X-rays confirming her injuries, but so far that and some pain medication is the only interventions she has had. Currently, the resources aren’t available to fly her out.  

I begin rounding with a local doctor, hopping from bed to bed mainly debriding wounds and changing bandages. In the midst of dressing a particularly large and infected wound, I hear one of my team members yell for me.

I turn around to see CPR being performed and one of the local MD’s bagging a patient. I rush over and stand at the head where the patient is being bagged and immediately realize how incredibly spoiled I am as far as medical equipment availability in the U.S. I ask for intubation supplies and an EKG monitor. We have neither available.

In that moment, I also realize that we don’t have a vent or the capabilities to keep a patient ventilated for any extended period of time. We don’t have the ability to support this incredibly sick patient. We settle on running the arrest using a portable SPO2 sensor. After several rounds of epi, we call the code. (Read more about this cardiac arrest patient and see a picture of Beach managing the patient's airway in a May 6, 2015 news article.)

I learn later that anyone dying on this day does not have to be reincarnated according to the Buddhist religion but bypasses directly to an enlightened state. It is Buddha’s birthday today and the religion holds that you are only reincarnated if you have more to learn on the path to enlightenment.

Making a difference: May 5, 2015
With the assistance of our Bhutanese cohorts, we are able to negotiate a flight out to a medical facility that can assist the young woman that lost her baby and has the unstable pelvic fracture. Our team initially arrived this morning and were met with one of the nursing students attempting to discharge this patient to her family.

I am incredibly relieved we arrived to catch it before it happened, and also that we were able to find a way to get her help. She’ll need surgery and ongoing care.

We have made a positive impact on at least one person. That alone makes this trip a win. Tomorrow we leave to go and host medical clinics in some of the villages surrounding the area.

Provider health and well-being
Being prepared for the experience of volunteering, physically and mentally, is of the utmost importance. The Centers for Disease Control and Prevention have travel health recommendations, including vaccinations, available online. Before departing your home country, make sure your vaccinations are up-to-date.

The organization for which you are volunteering may have additional recommendations or may be able to assist you with obtaining the necessary health screenings, vaccinations and documentation.

In the disaster zone, follow local recommendations for PPE, water and food consumption and sleeping conditions. Many countries have a variety of endemic diseases not normally encountered in the U.S. and you may be required to alter your daily routine. If you take medications, be sure to pack a supply beyond your anticipated stay.

Be aware of your own mental health and that of your fellow responders. There has been increased scrutiny lately about the long-term effects of chronic stress on EMS providers.

Responding routinely to medical and traumatic emergencies has been linked to increased episode of post-traumatic stress symptomology [5] and increased awareness of suicide among emergency responders.

It is important to note that responding and working in a disaster environment is a significant stressor and that acute stress can compound existing chronic stress symptoms. Awareness of stress is as integral to keeping yourself safe as PPE and vaccinations.

Exhaustion: May 8, 2015
We ended up seeing over 1,000 patients total at four different sites over the past several days. I am exhausted physically and emotionally.

Recovery and return
Eventually, your role in the disaster response will end. You will pack up and return to your life and your regular job.

Depending on the nature of the response, the recovery effort may continue for some time after you leave. Many responders struggle with feelings of guilt and frustration at the on-going nature of rescue and recovery in the wake of a natural or man-made disaster. The choice to stay or return becomes one of both logistical concerns and your individual health and well-being.

Another earthquake: May 12, 2015
I am several days overdue for my flight home after the airline cancelled our original flight, but today is the day. The past two days I have been staying at the Annapurna Hotel in Kathmandu.

I am in the process of taking a quick catnap prior to leaving for the airport when a 7.3 earthquake strikes. I am on the third story of the hotel. I immediately rush to a door frame and throw my shoes on, waiting for the shaking to stop.

My head is going a million miles an hour. I make it safely outside to the evacuation area. My phone has enough battery left to open Facebook and click a button saying I am safe.

I realize there is only one runway into and out of Kathmandu Airport. If it is damaged, we will not be leaving today.

I watch as LA County and Fairfax Fire (urban search and rescue) teams begin to organize and deploy out to new areas that have been impacted by this second very large earthquake, and I begin to tear up. All of the responders have been working so hard, we’ve done so much work and it’s not over.

Guilt and anger: May 12, 2015
After several hours, the hotel is cleared to enter back into. I pack my things and head to the airport for the very long journey home.

All of my creature comforts seem silly. I have extreme guilt for being able to even stay in a hotel. I feel guilty for having the ability to take a warm shower and to eat at will.

Thousands dead, even more injured and displaced from their homes. Cities crumbling.

I have seen how incredibly wonderful and resilient the Nepali people are in the wake of this devastation, but the reports coming back after this second large quake shade my optimism. I am mad at myself for the mere privilege I was born into and angry with Mother Nature.

I realize neither of these emotions are helpful.

Asking for help
Returning to work in the "normal" EMS system of your hometown can be a shock. You suddenly have a wealth of resources at your disposal and a new perspective on how those resources would have been useful in a disaster response.

The difference in need can be a stark reminder of what you saw and what you experienced. EMS providers often pride themselves for being resilient and able to compartmentalize effectively. While that may be true in the short term, your long term ability to continue to work in EMS relies heavily on taking time to process calls and events and sometimes getting assistance along the way.

Compassion fatigue: Summer 2015
Coming back home I've noticed that I’m holding on to a lot of grief, guilt and even anger. Being back on the ambulance is difficult right now. Seeing how people misuse and abuse the 911 system and its resources is abhorrent to me.

The mass country-wide destruction, thousands of survivors sick and wounded were either completely incapacitated or they were trying to rebuild their communities along with those that had not physically been injured. This to me is true pain and true need.  

I am absolutely in a state of compassion fatigue.

I’ve made several appointments with a counselor. I’ll need help to process all of this.

Update on Nepal
In the aftermath of the 2015 earthquake, Nepal still struggles to rebuild. While roads and other infrastructure in the capital of Kathmandu show progress, outlying rural areas barely have projects approved to clear rubble and many families are still living in temporary shelters. Medical clinics are set up in the crumbling buildings which remain and local providers are heavily taxed by the massive load of patients. Summer monsoons mean further delays to the rebuilding efforts. In one of the most geologically active parts of the world, recovery is slow and the risk of another large earthquake only increases with time since the last.

The first several months after the trip were somewhat rough for me. As a paramedic with more than a decade of experience in busy EMS symptoms, I do believe there is a slight baseline of compassion fatigue that I consistently court and consciously mitigate. I have made sure that I take care of myself physically and emotionally, sometimes the gym takes care of both. On occasion, I’ve found myself talking to a therapist. I had a rare, fantastic, and sometimes scary experience: I keep the memories and what I learned close to my heart. I acknowledge that a lot of it was incredibly overwhelming and heartbreaking. Life is just a work in progress.

About the authors
Julie Beach has been in EMS since 2003. She is currently based in Alameda County, Calif. Julie has a passion for furthering the education and ability of EMS systems to recognize and address PTSD among first responders. In her spare time she enjoys hiking, the gym and spending time with her loved ones.

An EMS practitioner for nearly 15 years, Patrick Lickiss is currently located in Grand Rapids, Mich. He is interested in education and research and hopes to further the expansion of evidence-based practice in EMS. He is also an avid homebrewer and runner.

References

  1. Rousselot, J. (2015, April 25). Nepal toll rises after worst quake in decades. Retrieved from http://www.aljazeera.com/news/2015/04/powerful-earthquake-hits-nepal-150425063918183.html?_sm_au_=iSVPHP5sJDLDNPDF
  2. Achenbach, J. (2015, April 27). Kathmandu shifts three metres in 30 seconds. Retrieved from http://www.smh.com.au/world/kathmandu-shifts-three-metres-in-30-seconds-20150426-1mtc5x.html
  3. Government of Nepal. (2015, May 1). Nepal Disaster Risk Reduction Portal. Retrieved from http://drrportal.gov.np/?_sm_au_=iSVPHP5sJDLDNPDF  
  4. Krishnan, U., & Mehrotra, K. (2015, April 28). Nepal Says Earthquake Rebuilding Cost to Exceed $10 Billion. Retrieved from https://www.bloomberg.com/news/articles/2015-04-28/nepal-rebuilding-cost-to-exceed-10-billion-finance-chief-says
  5. Donnelly, E. (2012). Work-related stress and posttraumatic stress in emergency medical services. Prehospital Emergency Care, (16), 76–85.

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