Roles and intervention aspects for

Physiotherapists in supporting

persons with disabilities affected by

natural disasters .

Eric Weerts , PT

HANDICAP INTERNATIONAL

Emergency Response Division

1

AIMS OF THIS PRESENTATION

1.Learn to differentiate emergency intervention from other types of responses.

2.Become aware of the main principles of intervention in providing adapted rehabilitation services in emergencies

3.Recognize the main technical aspects of physical rehabilitation and emergency

4.Understand the practical elements of implementing rehabilitation in emergencies through examples

5.Consult and retain some technical resources that can be used in emergency contexts and rehabilition

6.Learn about networks, organisations and operators in the field of Physical Rehabilitation and Emergency

2

1.Learn to differentiate emergency intervention from other

types of responses

• Do You know activities and situation that

require different types of responses in

physical rehabilitation ?

• Possible factors that influence response ?

• What is proper to an aftermath of a disaster ?

3

Factors - key terms

• Shifting needs in short time and notice

• Adaptation of mainstream physical

rehabilitation principles

• Complexity of issues arising in the same time

and space

• Forecasts of needs to consider in short term

• Future footprint of needs to anticipate

4

Transition to Development / Back to previous situation

Post emergency/ Early Recovery

Acute emergency

Adapting response to the evolving needs of the affected populations

Extremely vulnerable persons

(incl.PwDs)

Vulnerable persons

General population

Basic & Specific needs

Focus on specific needs

t

Possible answers :

• Time frame of intervention

• Cause / Reason for intervention

• Context /economic environment

• Level of interest of public / donors / media

• Means – technology

• Risk factors that will compound possible deterioration of context

• ,………………

6

Introduction to disaster/emergency

settings

The types of disaster that could cause or impact disability/injury prevalence can include :

– Earthquakes

– Typhoons

– Landslides

– Floods

– Armed Conflict ,….

Due to natural phenomena and climate impact on living environments

� Armed conflict situations are more forgotten in the literature ,….

7

It differs from a non-disaster setting

by:

– Destruction of pre-existing facilities / infrastructure, including damage to health care facilities and reduced capacity of care

– Risk of outbreaks of diseases/ not common before the disaster onset

– Destruction of means of communication

– Weakened coordination , disorganization of the usual health and support systems

– Challenges in identification and treatment approach due to high number of cases in short term

– Emergence of complex rehabilitation issues in the long term

– Security/ sanitation , self protective context of working environment

8

Broad and General principles on

emergency intervention in rehab care

• Extrication in challenging environments of victims

• Triage and First care with limited resources

• Surgical/medical attention

• Early Functional Rehabilitation

• Psycho-social support for patient and family

• Planning long-term rehab reintegration in post

emergency setting

• Define the need for skills transfer to local staffing

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Rational for Intervention on vulnerability

and physical rehabilitation

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Situation and outlook towards basic care and needed long term follow as lifelong

assistance ( needed for these affections ) is compounded by the breakdown of health

services and community support system due to the conflict such as:

•insufficient availability of emergency care for injured

•absence of prevention measures to reduce complications and additional disability

•No availability of early and long term physical rehabilitation services

•overload on remaining care institutions

•lack of medical supplies/equipment for basic quality care

•diminishing numbers of qualified health staff in care settings

•continuous displacement of vulnerable persons weakening their health status further

•Psychological insecurity burden on family members and caregivers of

injured/vulnerable not able to cope with this situation of constant insecurity

In emergency setting the situation can

shift + or - through :

• Timely arrival of recovery teams / aid

• Coordinated extrication/ evacuation efforts – Success depends on effectiveness of coordination between

different actors, local and foreign ones on the emergency theatre

• Triage / identification and First care– Rapid identification of cases by trained providers

– Concentrate on potential survivors in some cases

– Appropriate referral to a centralized point of care that can manage physical disability properly

– Resilience of the human factor to cope with conflicting situations, difficult and ethical choices to be made.

11

Forecasts of proportion of disabled

injured could depend on :

• The time of onset of the disaster in the day span ( night or daytime )

• Use of weapons/ arms in type of conflict

• Type of infrastructure and construction material used in buildings

• Policy and means for preparedness in the country / region of the disaster

• Local practice on preparedness ‘’culture’’ for disasters / emergencies

• Responsiveness of recovery teams in extricating victims within a critical window of time , as well as managing them in the first days after injury

• Availability or not of specialized equipment at extrication/identification that can be lifesaving

�It is difficult to forecast but relation deaths – injured ( 3 times more ) can be indicative

12

This situation gets complex when:

• Available rescue and recovery resources are limited

• Prioirities need to be set for victims that have the best chance of survival

• Limited resources need to be spread and focused on the most pressing needs

• External supporting staff has difficulties in coping with what they experience as professionals in a disaster setting .

• Identified victims with disability need dedicated long -mid term attention as opposed to other victims of the same disaster/context

13

Uncertain future footprint of needs

and burden of disability and injury • Rehab professionals know that :

- The burden of care will be important in the long term for family members / caregivers and society in case of permanent injuries

• Therefore it is important to allocate resources in a timely and balanced way in order to

– Ensure best possible management at all stages of disability

– Prevent costly complications and unnecessary treatments by smooth cooperation between surgery, rehabilitation staff social workers ,…

– Ensure maximal community integration and participation of family /relatives and care assistants in the process of support

– Be aware that charity attention span for support to disabled victims is high at onset of disaster but extinguishes in the long term when it is more/equally needed ,…

14

For persons with previous conditions , their

challenges in disasters are

• Inaccessible evacuation

and shelter options

• Damage/loss of accessible

homes and equipment

• Loss of care

supports/family

• Loss of income

(agricultural or other)

• PTS after violence / injuryTyphoon Ketsana, Vietnam 2009

Photo courtesy Eric Weerts, Handicap

International

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2.Main principles of intervention in providing adapted

rehabilitation services in emergencies

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Overview main points and

principles

2.1 Situation Analysis and Team work

organisation

2.2. Upgrading knowledge and Curriculum use

2.3.Awareness Education tools for Patients and

Caregivers

50 Min

Analysis and team work

• Increase of involvement of rehabilitation professionals in the aftermath of disasters since the last years

• Need to have more specialised human resources on the field

• Need to adress the complexities of the disaster theatre

• Better scientific documentation that highlights the challenges of needed long term follow-up of disaster events

18

Field Principles in Physical and

Medical Rehabilitation • Interdisciplinary approach in emergency

context must start early as possible

• Coordination of care activities must be streamlined in team approach

• Local health and rehabilitation staff needs training in PM/concepts

• Anticipation of long term needs of severely injured must start as soon as possible in order to prevent disibilitating consequences

19

Field conditions to start up

Rehabilitation program in emergency

context • Logistics and security frame work is validated

• Set up of local partnership to operate in the best legal conditions possible

• Transport and acces to trauma care units with a clear mandate and visibility prepared by the organization

• Formulated terms of reference that describe the task required for the rehabilitation responder : technical / managerial level

20

Basic roles for team leaders

• To ‘’ cement ‘’ a vision among the different stakeholders on trauma care on the importance of global and long term approach towards early identified victims, to act as a link between surgical/acute and rehab teams

• To assess in depth the medical aspects of rehabilitation medicine that are required for implementing trauma care and rehabilitation in safe conditions.

• To provide direct technical assistance in constituting adapted protocols that allow physical rehabilitation programs to function optimally

22

Transfer of knowledge role

• To participate in training the rehab team and non rehab staff in the sound management of trauma victims leading to a comfortable setting to implement physical rehabilitation

• To assist directly in care techniques not known by the mainstream trauma team, provide clinical analysis and interpretation of observations , manage complex trauma cases

• To assist the team in the diagnosis of complicated cases and clarify diagnosis and non- detected conditions

24

Personal skills of team members

• A mindset and attitude that should be resilient

towards insecure working environment , need

for prioritizing personal security and

respecting operational and logistical

procedures .

• Being able to cope with varying workloads in

terms of patient numbers and be flexible in

the team approach

26

Team approach in physical

rehabilitation

• Ideally the PM/R should be team leader of the most common profiles Handicap International is working with :

- Physiotherapists

- Occupational therapists

- Social workers

- Psychologists

Although these profiles are not present at once in the timeline of projects ( 5 – 8 months ) , the team leader needs to ‘’ bridge ‘’ their absence by increasing of task sharing and coaching of the team

28

Conclusion

.Rehab team leaders are a key Human Resource in disaster setting.

.Their specific skills and know how should be placed within the available rehabilitation teams made up of physical therapists , occupational therapists , psychologists and nurses during an emergency.

.Special efforts should be done to identify the needed skills and allow these skills to be used on the field and the team setting beyond the pure medical standard of operations.

29

3. Upgrading knowledge and

Curriculum use :

Creation process of teaching materials for

upgrading Physical rehabilitation knowledge on the

Syria crisis intervention

30

Main objectives of training

intervention• Identification of needs among injured and

displaced population ( SCI and others )

• Provision of care and technical aids

• Training of Syrian Therapists and Rehabilitation workers

• Develop strategy elements for near future rehabilitation systems

31

Main features of the teaching materials

• Teaching materials seek to address the urgent needs of having in a short time training materials available for PT and Rehab workers .

• It includes as a first step short training sessions for Syrian physiotherapists and Health sector professionals (who will assist physiotherapists).

• This training material allows them to better deal with war-related injuries and/or disabilities in an emergency context.

• People who will attend to this training will be Syrian physiotherapists and or rehab workers graduated/ working in health structures (hospital, rehabilitation center…) in Syria.

• The training period takes place during five days with a maximum of 8 participants.

• Continuing education , activity sheets and technical supervision ensure follow up and quality control after this basic training

32

4 . Used ressources

PTA

MANUAL

Standard Contends PT/RW

Module 1: Methodology for rehabilitation cares and advices in emergency approach

Module 2: Rehabilitation assessment

Module 3: Rehabilitation cares and advices

Module 4: Mobility devices and specific items

Module 5: Prosthesis and orthotics

Module 6: Environment management (advices on accessibility)

Module 7: War injuries rehabilitation management

Module 8: Psychosocial approach

34

Additional features

Quizz to test knowledge

Powerpoints for delivery of teaching ( Arab/Eng)

Protocols of care for conditions

TOT module for team leaders / manager roles

Resources on web in arabic/ english

35

36

37

Protocol of care

38

39

Context of teaching and delivery

-Face to face teaching for PT / RW

-Teaching on distance for remote project

-Mix of both modalities

-Back up of rehabilitation supervisor to ensure

quality in practice delivery if needed according

project sites

40

Limits of curriculum

• Short cut of curriculum process

• Focused on contend and fast delivery

• Continuing education process does not follow

the needs of long term approach

• Roles of PT and PTA on the field

• Thin line between PT and RW in Syrian

education PT ,…

41

Early rehab protocol

• Destined for hospital PT

development

• Good shift between

emergency and long

term development

• Guide and reminder

tool for knowledge

upgrade

50 Min

Checklist knowledge

50 Min

Practical implementation kits for wheelchairs and

temporary prosthesis

• Emergency wheelchair

• Temporary prosthesis fitting

50 Min

Emergency wheelchair

50 Min

Characteristics

• Bright color for visibility

• Fast assembly ( ‘’ ikea ‘’ type )

• Accessories : cushion , basic maintenance

• Interchangable materials

• Life expectancy : 8 – 9 months in difficult

conditions

• Training of staff in 2 days

50 Min

Emergency Response Wheelchair

Training PackageDay 1

1230 Introduction and background to project

1300 1. Emergency wheelchair provision overview

1330 2. Emergency Response Product

1445 3. Eight Steps of Wheelchair Service

1515 BREAK

1530 4. Intro to Assessment/Prescription/Fitting form

1545 5. Assessment/Prescription/Fitting Skills

1630 6. Assessment/Prescription/Fitting Skills

1730 7. User training demonstration and practice

1830 FINISH

Day 2

0830 Review from Saturday/questions

0900 8. Rapid Response Wheelchair Service Set-Up

0945 BREAK

1000 Micro training sessions

1200 Feedback and discussion

1300 FINISH AND LUNCH

Wheelchair Service Levels

WH

O S

erv

ice

Le

ve

ls

Ba

sic

Users of manual wheelchairs without modifications

Inte

rme

dia

te

Users of manual wheelchairs with supportive seating

Ad

van

ced

Users of complex supportive seating and mobility equipment

Em

erg

en

cy

People in an emergency situation who need a wheelchair

immediately.

Selection of type of fitting

50 Min

Demo fitting process

50 Min

Principles - Recommendations

� Amputation usually means disability;

� In order to decrease as much as possible

the level of disability and to improve the

surgery’s outputs, medical services should

be accompanied with rehabilitation

services (Sphere Standards, WHO 2011

World Report on Disability);

� Input from rehabilitation should start pre-

operatively (level of amputation) and

follow-up should be provided until returning

home (social inclusion);

� Early rehabilitation and provisional

prosthetic services are possible, even in

emergency situation.

52

4. Education tools for Patients and Caregivers

• General principles for education tools :

- Use of basic language

- Easy to translate

- Use of visual designs

- Inquire about local culture and custom

regarding information spreading

50 Min

Information in pathology -

outcomes

• Contend should not be technical

• Do not use comparitive information regarding

outcome

• Do not refer to medical diagnosis – file

information regarding long term outcomes

• Be careful on advising further medical

treatments

50 Min

Examples information

50 Min

Should lead to advise

50 Min

Exercise programs

50 Min

Patient and family

information/education systemsDuring the aftermath of a disaster , this issue is one of the most critical ones due to :

-Need for early information provision on disability and injury status towards family and patient , ideally supervised as early as/when possible by a trained psychologist/social worker / counsellor understanding local culture and custom

-Coping of family and patient with aftermath of disaster in general ( affected communities , families ) as in particular ( change in routines/ life after injury )

-Need to understand promptly the crucial role of family / care attendant in the long term physical and social rehabilitation approach within local cultural context

-Need to have support from care attendants to relieve the ( limited ) health staff on the disaster/emergency theatre while safeguarding the quality of the care and avoiding complications ( ex: avoid unsafe log rolling and/or poor hygiene during handling , sustaining therapeutic exercise ,… )

59

Patient and family

information/education systems (cont)

Pamphlets need to :

– be as simple as possible with

• Few text

• Lots of images

– allow

• Fast translation in local language

• Easy understanding for illiterate persons

• Use comic strips for persons with limited illiteracy

• Give insight to local health staff not familiar (yet) with rehab management

60

Courtesy of F Stephenson

Types of interventions regarding

information and education (cont)

- Individual counselling ( early stage )

- Group education that allows sharing of ideas and

answers to questions

- facilitate linking with medical teams

� Provided by trained resource persons to

patients and their families

- Peer support ( later on )

–Issuance of practical dedicated information

–Giving Emotional and mentor support

� Provided by trained peers with life experience in

disability 61

Known practices during interventions

• Uphold the continuum from acute/surgical care /rehabilitation towards integration

• Cohort identified patients in designated physical rehabilitation sites with family support

• Initiate training/mentoring in under-resourced regions for short and long term goals

• Foster coordination of care between stakeholders of care in emergencies and long term development

• Ensure that patients carry their disability background information with them in the continum of care to avoid drop out of follow-up when moving to other places . Courtesy of F Stephenson

Interactive websites

• www.Physiotherapyexercises.com

• http://www.tbistafftraining.info/index.html

50 Min

5. International Resources

• International Professional networks have special

features on emergency – disability :

- International Society for Physical Medicine and

Rehabilitation

- World confederation of Physical Therapists

- World confederation of Occupational therapists

,…………………..

50 Min

International NGO – technical

thematics • MSF ; HI , CBM , Doctors of the World , IMC

• UK MED : UK International Emergency Trauma Register

(UKIETR)

• Handicap International UK is managing the PT

preparedness training

• http://medbox.org/ : resource site with available technical

documents

• http://www.rehabmonitor.org/ distance education resources

50 Min

Main guides

66

http://www.sphereproject.org/resources/download-publications

67

Side remarks

- Gives an overall view on minimum standards

- Describes the context in wich Rehab actors

have to work

- Is not rehab specific ( should be reviewed

- Broad base of editorial resources ( NGO ; IO ;

experts ,…)

- Is used as an international tool for goverments

and some UN agencies

68

Technical guidelines

• http://www.who.int/

hac/global_health_cl

uster/fmt_guidelines

_september2013.pdf

?ua=1

69

Main contends

70

Regarding physical rehabilitation

• Better need to

define PT services

• Needs additional

protocols for each

condition

• Work in progress (

WHO – international

organisations

• Helps to compare

capacities

• Readable standard

for international and

local actors

71

Disability checklist

72

Awareness tool for

73

Health

74

HI tool’s rational

• Broad awareness for

other humanitarian

actors not familiar

with Disability

• Teaching guide for

field workers

• Houses the issues of

physical disability in

health

75

Others

• Psycho social issues

• Protection of

children and women

• Accessibility

• Rights of victims of

disasters and

conflicts

• Issues that the actors

on rehab care might

be confronted with

76

Examples

77

Adapt to local needs

• Consider environments, resources, culture of the disables / injured persons

• Educate patient and family within local context and participation

• Assess/consider carefully unforeseen outside interventions

78Courtesy of F Stephenson

Conclusion on characteristics of

disability in emergency • Factors like time – context – nature of disaster – type

of conflict – shifting needs in short notice differentiateemergencies from development

• Guides and principles of emergency interventions provide basic classification of rehab activity in emergency management

• Physical rehabilitation , comprehensive approach on disability and capacity building need to be adaptedand refocused to be effective

• Disability factors of injured and prevention of permanent disability are not well known amonghumanitarian stakeholders . This needs to be more advocated .

79

Thank You

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