Molly J. Hall, Ann E. Norwood, Robert J. Ursano, Carol S. Fullerton


Biosecur Bioterror. 2003;1(2) 

In This Article

Early Management of Casualties

There have been a number of disasters, terrorist attacks, and the use of novel weapons in the context of war which suggest that hospitals, medical clinics, and offices of healthcare providers may be deluged with patients seeking evaluation and care.[19] Arousal and intense anxiety may be experienced as multiple, varied somatic symptoms such as heart racing, shortness of breath, flushing, and nausea. Virtually any organ system may be involved. Acutely traumatized, frightened individuals may easily attribute these physical sensations to the CBRNE agent. During the Iraqi scud missile attacks on Israel between January and February 1991, over 1,000 people presented for emergency care but only 22% had been directly injured.[20] The overwhelming majority of patients were behavioral and psychological casualties, suffering from acute anxiety, side effects of auto-injected atropine, injuries sustained running to safety, suffocation from incorrect gas mask use, or acute myocardial infarction. Following the 1995 Aum Shinrikyo sarin gas attacks in Tokyo, which killed 11 people, over 4,000 people who showed no signs of exposure sought emergency medical care.[21]

Triage of patients who are primarily distressed and may have somatic symptoms from those who may have been exposed or injured is a critical and challenging first step in emergency care. The term "worried well" is disparaging and should never be used. The patient immediately feels that their health concerns have not been taken seriously and that they have been told "it's all in your head." A nonstigmatizing triage labeling system such as high risk, moderate risk, and minimal risk conveys concern and promises continued monitoring, which is reassuring to patients. Ideally, psychiatrists, or psychiatrists working with other mental health professionals, should be an integral part of the teams performing initial screening and triage. It is important to maintain mental health care in conjunction with other medical assessment and care. Patients who remain fearful and are not reassured by negative findings may be best cared for in a set aside area co-located with the emergency department. This allows for continued evaluation and easy return to the emergency department if necessary. Establishing a clinical registry to follow up patients who are distressed is a sound public health intervention as well as a psychological intervention, assuring patients that their concerns are being taken seriously.

The most important element of psychological first aid is good medical care.[22] This applies to communities as well as to individuals. A well-organized, effective medical response instills hope and confidence and reduces fear and anxiety. Initial psychological interventions should be focused on well-being rather than mental health. Encouraging sufficient rest and sleep, normalizing eat-sleep-work cycles, and limiting exposure to media reports and traumatizing images and sounds are all measures that facilitate coping and recovery.


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