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Aga Khan University nurses at forefront of earthquake disaster

by Rafat Jan Rukanuddin

“There were thousands of crows in Muzaffarabad. However, two days before the quake, no one had seen any crows and, a few hours before, no birds had been seen at all. Near the time of the earthquake, all the animals became quiet and sat in a corner. We missed these natural signs! When the quake happened, the earth shook like a roller coaster. Inside our homes, we were swinging as if we were in a boat on rough sea water!”

AKU nurses responded under less-than-ideal conditions to the physical needs of Kashmir earthquake victims.

Many residents of Kashmir told a similar story in the aftermath of the earthquake that shook Kashmir in the early morning hours of Oct. 8, 2005. One of the most powerful earthquakes ever to rock South Asia, it registered 7.5 on the Richter scale ("Devastating Quake," 2005). To date, almost 80,000 deaths have been reported. During the disaster, the Pakistan Nursing Council called upon nurses of Aga Khan University (AKU) to join its relief action and to support the nurses of Muzaffarabad.

Our group of 10 nurses from AKU left Karachi, Pakistan, on Oct. 14, six days after the earthquake. We were the second of four relief groups to respond from AKU. When we stepped off the plane and were taken to the local hospital, Abbasi Institute of Medical Sciences (AIMS), we could not believe the number of casualties. They included injuries, loss of limbs and paralysis. Families were torn apart. Amidst all the destruction, two nurses—their eyes red and swollen from lack of sleep—toiled on despite the tiredness and trauma etched into their bodies and faces.

AIMS, located in Muzaffarabad, the capital of Kashmir, is a government hospital with one residence for female nurses. Following the earthquake, the hospital building had some cracks, and the female nurses hostel was the only other building not reduced to rubble. Formerly providing tertiary care to the people of Muzaffarabad and adjacent areas, AIMS became the hub of all health-related activities following the earthquake. It was the only health institution acting under a no-right-for-refusal policy regarding receipt of patients.

The infrastructure was almost nonexistent. There was little access to basic emergency supplies and services such as linens, bedpans, narcotics and laundry. Physicians and surgeons functioned in a volunteer capacity, some for three days, others for a week or two weeks. Prior to the arrival of the AKU nurses, the two AIMS nurses worked continuously for four days and nights without the aid of other human resources—such as housekeepers, ward boys or assistants—for routine patient care.

After an initial assessment of the situation, the AKU nurses recognized that they needed to provide full coverage of nursing for patient care. Five nurses provided care in the two hospital units and emergency department, and four nurses provided care in the two other units. During the initial week, AKU nurses worked 13 to 14 hours daily. Subsequently, they worked 12 hours each day to provide full coverage. The team leader served wherever the need was most urgent.

Earthquake aftershocks Members of a team affiliated with the Mental Health Outreach Project who traveled to Pakistan to help victims of the Kashmir earthquake reported the following upon their return to the United States in late January 2006: Many quake survivors were still in tents, the majority without heat, hot water or running water. Hygiene was inadequate, with respiratory infections, pneumonia and scabies spreading rampantly. More than 75 percent of quake victims exhibited moderate to severe levels of post-traumatic stress disorder. Expressed most frequently by victims were the following: fear of repeated earthquakes, fear of going back to their homes, uncertainty about the future, nightmares, flashbacks, feelings of hopelessness, hypervigilance and somatic complaints. Survivors frequently observed that, as a result of the quake, they had learned to: 1) help others, 2) be more accepting of that which they could not change, 3) focus on the moment, 4) manage their feelings, 5) gain more self-confidence, 6) become more trusting of God’s will, and 7) trust their coping abilities. Those who interpreted the quake as a punishment from God or Allah were initially unable to identify a positive lesson, but with the aid of counseling by team members, were eventually able to express feelings of guilt and work through their emotions and beliefs to discover a positive lesson. —Adapted from a report by Anie Kalayjian, RN, EdD, director of the Mental Health Outreach Project. For more information about future outreaches to aid quake victims, visit www.meaningfulworld.com.

Nursing priorities
The initial nursing analysis of disaster-related needs focused upon physical needs of earthquake survivors. This was followed by an ongoing assessment of the psychosocial and spiritual needs of the people of Kashmir and their health professionals.

Our initial patient assessment revealed a number of acute physical care needs, including: 1) a high level of undertreated or untreated pain; 2) wound infections and the associated need for dressing changes; 3) skin integrity problems such as bedsores, foot sores, and abrasions or breaks in the skin of the face, hands and other body parts; 4) lack of environmental cleanliness; and 5) lack of facilities and supplies for personal hygiene which, in turn, led to other skin problems such as scabies.

Our ongoing psychosocial assessment found a number of unmet needs including: 1) fear of buildings collapsing and additional earthquake aftershocks; 2) recall of painful memories consistent with post-traumatic stress disorder, including muteness, crying and screaming; 3) lack of physical and psychological care for orphaned children, including failure-to-thrive newborns whose mothers had expired during the disaster; 5) uncertainty related to the status of family members and friends; and 6) hopelessness regarding post-disaster life.

Nursing interventions and outcomes
After completing our initial assessment, nursing interventions of earthquake survivors included: 1) pain management; 2) infection control measures; 3) prevention of bedsores and promotion of skin integrity; 4) maintenance of physical and environmental hygiene and safety; 5) care of orphaned children; 6) counseling, conditioning and consolation of patients and relatives to maintain emotional integrity; and 7) instillation of hope. As a result of our care and quick decision-making, only one death, that of an older lady with many adverse health conditions, occurred.

Challenges and barriers to effective disaster response
Several barriers to effective nursing action and positive survivor outcomes were encountered in the immediate post-earthquake and initial two-week recovery period. Included among these challenges were: 1) lack of electricity and water, 2) feelings of loss of control by survivors and nurses, 3) inadequate pain management, 4) documentation difficulties; 5) lack of interdisciplinary collaboration; 6) insufficient financial resources for post-disaster recovery, 7) lack of a local nursing services director, and 8) inadequate support of relief workers.

Three recommendations are offered to nurse teams responding to future natural disasters in Pakistan: 1) the need for adequate personal supplies, 2) improved access to communication technologies, 3) the need for follow-up of health assessment and treatment, and 4) additional education/training for government nurses.

Impact of relief efforts on the future of nursing in Pakistan
This was the first time in the history of Aga Khan University that a group of nurses went as an independent team to a disaster site and provided care to patients with a non-AKU medical team. Though lacking previous experience in emergency relief, the AKU nurses provided much-needed care at the hub of the Muzaffarabad relief effort. Nurses met with and provided care to the general public and interacted with various medical and paramedical teams from throughout Pakistan. The nurses adjusted to the rapidly changing teams of volunteers, while working hard to fulfill the demands and expectations of patients and other health care professionals.

Our presence instilled an extremely powerful image of hope among the Muzaffarabad community. Patients and medical teams asked us, “Are you Pakistani? Have you come from Pakistan?” Many patients who traveled long distances to Muzaffarabad told the AKU nurses, “We had heard about your work.”

The medical teams were among those who applauded the AKU nurses the loudest, followed by Ministry of Health administrators. The president and vice president of the Pakistan Orthopedic Association showed high respect for the AKU nurses and team leader. Before leaving the Abbasi Institute of Medical Science, the vice president of the Pakistan Orthopedic Association came to the unit and saluted the team leader in front of all the patients.

The AKU nurses worked extremely hard, intelligently and cooperatively, providing care with compassion and competence in a highly challenging environment. They presented the best image of nurses, the nursing profession and Aga Khan University School of Nursing. Because of the great impact that they made in saving and preserving life and restoring optimal health to earthquake survivors, the people of Muzaffarabad and Kashmir will always remember the nurses of AKU. RNL

Rafat Jan Rukanuddin, RN, PhD, team leader in the AKU nurse response to the earthquake in Kashmir, is assistant professor and director of BSN and post-RN BSN programs at Aga Khan University School of Nursing in Karachi, Pakistan.

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Reference

Devastating quake kills thousands. (2005, October 9). Dawn, the Internet edition, para. 4. Retrieved March 14, 2006, from http://www.dawn.com/2005/10/09/top1.htm