Atypical patient profiles common after disasters

Be prepared for psych casualties

ED managers recognize the need to prepare their departments for a huge surge of patients in the wake of a disaster in the community. What some of them may not be as well prepared for is the very unique distribution of complaints and patient types that will present in such situations, experts warn.

For example, in the wake of disasters such as hurricanes Katrina, Rita, and Wilma, it’s important for ED managers to not only treat the physical problems of their patients, but to also understand there may be behavioral health problems related to their experiences, says James Shultz, PhD, director of the Center for Disaster Epidemiology and Emergency Preparedness (DEEP) at the University of Miami School of Medicine. Accordingly, he says, behavioral health consideration should be part of disaster planning.

"We ask people to think behaviorally," says Shultz, who follows a "Surge, Sort, Support" model of disaster response. "There may be psychological casualties: people who are fearful and in distress, but who may as a result of that fear generate physical symptoms," says Shultz. "In situations where there is advance warning, such as with hurricanes, there will also be a considerable surge of people trying to gain admission who are oxygen dependent, homeless, or who have special needs."

Another aspect of surge ED managers should consider involves family members, says Shultz. "While many people are self-referred on evacuation, some may be brought in by family members," he notes. "You may also have a big influx of people looking for missing loved ones, as the ED is a main access point to the hospital. Again, this is not typically something we make part of our disaster preparation drills."

Shultz suggests the ED have a place available that can function as a support center. "It’s good to have a place for observation and information where you can treat psych casualties, provide psychological first aid, and do behavioral triage," he says. This triage involves distinguishing the many patients who are distressed but who could be helped by being brought out of the ED to a more calming place, such as a classroom, from those who are inconsolable, agitated, or disruptive — those who have to be referred for further evaluation. "The majority will regain control and be ready for discharge," says Shultz. The treatment might be provided by behavioral health professionals, but could also include nurses, medical staff, or chaplains, he adds.

Triage is upside down’

In disasters that involve evacuations, such as hurricanes, the normal rate of emergency medical services (EMS) vs. self-referred patients is nearly reversed, which impacts the "sorting" aspect of your response, says Shultz.

Historically, about 88% of your patients are EMS transports, he says. In communitywide disasters, 80% are self-referred, Shultz says, and the first time a patient is seen by any medical professional is in the ED. "This leads to upside-down triage," he says. "You may be full up in the ED before the first emergency vehicles arrive."

Given this reality, it’s important to prepare for the different types of patients you will see, Shultz says. "You will have a complex blend of medical casualties, more minor injuries, and if they have been at the scene, the patient is more likely to be psychologically traumatized," he says. A lot of patients will have unexplained physical symptoms, Shultz says. "During disasters, you will have more of that [due to stress and trauma]." You may see mass psychogenic illness, Shultz says. In Israel, for example, when the Iraqi SCUDs fell, most patients had respiratory complaints, but there was no gas onboard the missiles, he says. "These patients need to be worked up in the ED until you find no physical basis for the complaints," Shultz says.

Staff are victims, too

In considering the behavioral health issues that often result from disasters, it’s important to include your ED staff, says Joseph A. Barbera, MD, co-director of the George Washington University Institute for Crisis, Disaster, and Risk Management in Washington, DC.

"Your staff can definitely be impacted," he says. "So, when you are creating your ED disaster plan, you have to ask if it makes sense from a behavioral point of view." In other words, he poses, do you have people "assigned to do 10 things at once, three of which are life-critical? If that can’t be done, what does it do to your people?"

When you add extraordinary circumstances, involving more victims than normal, with a totally different profile from everyday ED patients, this puts a huge amount of professional stress on your staff. "You must also consider the fact that they are victims as well," Barbera advises.

Make sure they have ample food and rest, and respect their need to find out if their family members are OK, emergency management experts advise. Your role can include items as simple as getting them food at the appropriate time. As an ED manager, observe them for signs of stress on an ongoing basis — especially those with young children. If need be, offer them a comfortable, quiet lounge to sit for a little while. Near the end of the incident, offer them critical incident stress debriefing with staff behavioral health professionals, they add.


For more information on behavioral triage, contact:

  • Joseph A. Barbera, MD, Co-Director, George Washington University Institute for Crisis, Disaster, and Risk Management, The George Washington University, 1776 G St. N.W., Suite 110, Washington, DC 20052. Phone: (202) 994-8424. E-mail:
  • James Shultz, PhD, Director, Center for Disaster Epidemiology and Emergency Preparedness, University of Miami School of Medicine, Highland Professional Building D-93, 1801 NW Ninth Ave., Miami, FL 33136. E.-mail: