On December 26, 2004, a violent earthquake measuring 9 on the Richter scale struck off the western coast of northern Sumatra. It initiated several tsunamis (tidal waves) that took more than 200,000 lives. It was the deadliest natural disaster in the past quarter of a century. But as horrible as it was, it was but a ripple compared to some quakes in recorded history.
In 1556, an earthquake in China took the lives of 830,000 people. In India, an earthquake in 1737 killed 300,000. Almost thirty years ago (1976), a massive quake in China left 655,000 dead.
The Sumatra quake, which scientists have measured with modern instruments, was so powerful that it is believed to have moved some islands about 50 feet. In addition, seismologists think that it wobbled the earth on its axis, accelerating the rotation speed, thus shortening the length of our day by fractions of a second – which is remarkable in view of the planet’s precision movements.
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The 2011 earthquake off the Pacific coast of TÅhoku (TÅhoku-chihÅ TaiheiyÅ Oki Jishin), often referred to in Japan as Higashi nihon daishin-sai was one of the five most powerful earthquakes in the world since modern record-keeping began in 1900.The earthquake triggered powerful tsunami waves that reached heights of up to 40.5 metres. The earthquake moved Honshu (the main island of Japan) 2.4 m east and shifted the Earth on its axis by estimates of between 10 cm and 25 cm. This earthquake claimed 15,878 lives, left 6,126 injured, and 2,713 people missing . The earthquake and tsunami also caused extensive and severe structural damage in north-eastern Japan . Japanese Prime Minister Naoto Kan said, “In the 65 years after the end of World War II, this is the toughest and the most difficult crisis for Japan.” Around 4.4 million households in northeastern Japan were left without electricity and 1.5 million without water. The tsunami caused nuclear accidents, primarily the level 7 meltdowns at three reactors in the Fukushima Daiichi Nuclear Power Plant complex, and the associated evacuation zones affecting hundreds of thousands of residents. The World Bank’s estimated economic cost was US$235 billion, making it the most costly natural disaster in world history.
Besides these, there have been the super cyclone in Orissa, earthquakes in Latur and Gujarat all of which have caused massive loss of life, distress, discomfort, disease and disability. Inspite of all this, we still await the so called Diego Maradonna’s ” Hand of God” to bail us out of each natural crisis causing incident.
In the past fifty years more than 10000 natural disasters have been reported, more than five billion people have been affected, more than twelve million persons have been killed and the economic costs have been greater than US dollars four trillion. In India during the period 1990 to 2006 more than 23000 lives have been lost in six major earthquakes(Uttarkasi, 1991;Latur,1993;Jabalpur,1997; Chamoli,1999;Bhuj,2001;J&K ,2005.) Enormous damage has been caused to property and public infrastructure. The twin super-cyclones that hit Orissa in Oct 1999 affected 24 Districts, 219 blocks and 18790 villages resulting in loss of 8495human lives, 450,000 lives of cattle and damaging two million homes and 23000 schools. The Bhuj earthquake was a terrible human tragedy in which13,805 lives were lost that included 1031 school children and around 167,000 persons suffered multiple injuries This was in the wake of two consecutive years of drought.
At the cost of repetition in the text it is important for us to understand and comprehend the term disaster. Disaster is a term very often figuratively used in day to day parlance. For instance, if, as professionals, you are making a presentation on some of your work which you highly value and the response of the audience is not exactly as per your expectations despite your utilizing all available resources, you would generally refer to such a presentation as being a “disaster”. Thus disaster is an unexpected event in which there is a sudden and massive disproportion between the hostile elements of any kind and the survival resources that are available to counterbalance these in the shortest period of time. There is no generally accepted definition of disasters. A study by Debacker found greater than 100 definitions of disaster. The variations occurred with professional role. The commonalities in all definitions are that disaster is a sudden and an extraordinary event wherein the demand for health care resources is greater than those that can be supplied, where outside help and resources are needed and which causes disruption of infrastructure, loss of life, material damage and distress. In short disaster is an event where the response needed is greater than the response available. One of the more professional definitions of disaster (Humberside County Council UK) would read as under:-
“Disaster is a major incident arising with little or no warning causing or threatening death or serious injury to or rendering homeless, such numbers of persons in excess of those which can be dealt with by the public services operating under normal procedures and which calls for the special mobilization and organization of these services.”
As we are deliberating on natural disasters, it may be worthwhile bringing out the fact that the Indian subcontinent is amongst the world’s most disaster prone areas with approximately 60 % of land mass is prone to earthquakes of moderate to high intensity, 8% of land vulnerable to cyclones, 12% of land mass is vulnerable to floods and 68% of cultivable area is prone to drought. The hilly areas are constantly at risk from landslides and avalanches and flash floods. With its vast territory, large population and unique geoclimatic conditions, the Indian subcontinent is exposed to natural calamities and catastrophies. While the vulnerability varies from region to region, a large part of the country is exposed to natural hazards which often turn into disasters causing significant disruption of socio-economic life of communities and to loss of life and property.
For the ease of understanding Natural disasters could be classified as depicted in the Figure.
Classification of Natural Disasters
(a) Natural phenomenon beneath the earth’s surface
¬Earthquakes including Tsunamis
(b) Natural phenomenon at the earth’s surface
(c) Meteorological/hydrological phenomenon
¬Cyclones ¬Typhoons ¬Hurricanes
¬Tornados ¬Hailstorms ¬Sandstorms
¬Floods ¬Sea-surge ¬Droughts
Characteristics of Disasters
Before we proceed any further let us briefly enumerate the characteristic features of a disaster since these will help us subsequently in formulating an appropriate disaster management strategy. The overwhelming characteristic features of a natural or any other type of disaster are:-
(a) Suddenness of Occurrence.
(b) Vastness of Damage.
(c) Loss of Life and Property.
(d) Disruption of Communication.
(e) Panic and Anxiety.
First Day First Person Ground Zero – Report From Military Hospital Bhuj – GS Sandhu
“Masses of humanity, crushed and mutilated limbs dangling, heads split open, shattered bones, and people coming in endless streams, tugging at the doctor’s sleeves to leave the patients they were attending to come and see their near and dear ones, crying, sobbing, screaming. This is the lasting impression of 26th January 2001 which I will carry with me for the rest of my life.”- Extract of author’s interview in Indian Express dated 8th February 2001.
1. Though the Kutch district of Gujarat is located in Seismic zone V, there was a general lack of awareness of the seismic risk and its implications among all sections of the society. The earthquake struck without warning at 0846 hrs on 26 Jan 2001. The epicenter was located 30 km north-east of Bhuj and measured 6.9 on the Richter scale. The impact was sudden and devastating. The local community was overwhelmed by the magnitude of the disaster and its resources rendered non-functional.
2. Military Hospital Bhuj is a small peripheral hospital, providing medical cover in the basic specialties. In the aftermath of the earthquake, this hospital acted as the first and sole responder, despite having suffered severe structural damage and its personnel and their families also being victims of the natural calamity. The principal task was to ensure operational readiness of the hospital for mass casualty management. A number of concurrent activities were initiated. Multiple reception, triage and resuscitation stations were set up. Indoor patients were moved out because of recurring aftershocks. Salvage of equipment and stores from collapsed buildings was commenced. An improvised surgical zone with makeshift operation tables was set up on hard standing. Pre and post operative areas were marked adjacent to this zone. Patient holding and evacuation areas were demarcated. Doctors from the town came to help in looking after the sea of injured humanity pouring into this sole medical facility functioning in the disaster zone. The local army formation provided generator sets, water tankers, tents and personnel for crowd control.
3. A simple standardized patient management protocol adapted to the locally available resources and skills was devised. The aim of this protocol was to standardize treatment, save lives, prevent major secondary complications and prepare casualties to withstand evacuation to hospitals outside the disaster zone. Graded assessment was carried out, to cope with the sudden massive influx of casualties. Paramedical personnel did the initial assessment by grading the casualties into major and minor injuries. All patients with major injuries were resuscitated with IV fluids and exhibited antibiotics and parenteral Diclofenac analgesia. The physician and medical officers carried out airway management. The gynaecologist, who was also the administrative leader of the team, triaged the patients into those whose injuries could be handled locally and those who would require definitive management at specialized facilities. The final decision as to the salvage of limbs was performed by the surgeons at the operating table itself.
4. An idea of the difficult circumstances in which this emergency humanitarian action was executed can be gauged by the following situation in the immediate aftermath of the earthquake
a) Collapse of the civil command and control structure in face of the magnitude of the disaster
b) Structural damage to Military Hospital Bhuj
c) Suboptimal / Inadequate surgical conditions
d) Lack of communications
e) Lack of water and electricity supply
5. Despite these constraints approximately 3000 casualties were handled at MH Bhuj before the first relief teams arrived around 2300 hrs on 26 Jan 2001. The problems encountered in handling casualties in these large numbers related to
a) Crowd control
c) Shortages of essential supplies
d) Biomedical waste disposal
e) Monitoring of the seriously injured
f) Disposal of dead bodies
g) Evacuation to specialized facilities
6. No country or community can be fully prepared to deal with sudden impact disasters. During the first few hours or even days, the affected community is isolated and must cope up the best it can. In a disaster situation the functions of the armed forces closely parallel those of the emergency services. The armed forces are trained to develop quick response capabilities. Their management and administrative systems function in a self contained, self sufficient and coordinated manner. The armed forces medical services have contingency plans and training to cater to mass casualty management. These capabilities allowed a small peripheral hospital to act as a sole responder to a disaster of overwhelming magnitude.
The author was commanding the military hospital at Bhuj, Gujarat on 26th January 2001
Medical Role and Organization
As we can see the management of natural disasters involves a host of disciplines working together to combat the ills and adverse effects of the disaster incident .This text will, however, be restricted to the medical role and organization during disaster incidences. This, however, in no way, is meant to malign the importance of other public services and agencies which are equally essential and play a vital role in the management of natural disasters. In fact these agencies contribute immensely towards successful and effective implementation of any disaster management strategy and are complementary to the efforts of the medical organization.
The medical role will depend upon :-
(a) Nature of the Disaster
(b) Medical organisation set up for combating the natural disaster
(c) The degree of involvement of the elements of the medical organisation in the Disaster incidence ie whether a hospital providing relief and rescue assistance is involved or not involved in the disaster situation
The primary element of any health care delivery system that comes into operation during a natural disaster is the hospital. The role of a hospital will vary, depending upon the prevailing scenario :-
(a) The hospital itself is not involved in the disaster.
(b) The hospital is directly involved in the disaster.
(c) The hospital is indirectly involved in the disaster.
(d) The disaster affects the hospital only.
In case the hospital is not itself involved in the disaster situation it can be geared up fully to meet the demands of such an eventuality. In case the hospital is directly affected by the disaster situation it will then be affected in the same manner as the general population and will then have to reorganize itself to provide medical aid not only to the community but also its own inmates and staff. In situations where the hospital is indirectly affected by disruption in some of its facilities and services like water and electricity supply, communication facility it will have to appropriately modify its own plan of action. These aspects have to be built into the disaster plan of the hospital.
Aims and Objectives of Medical Role and Organisation During Natural Disasters
The aim of any medical organisation during a natural disaster is to provide prompt and effective medical care to the largest number of people needing that care in order to bring about early recovery and reduce the death and disability associated with the disaster incident. A paradigm shift is needed from traditional approach to a casualty under normal circumstances. The approach has to shift from the traditional “ALL FOR ONE” to “ONE FOR ALL”.
The primary objectives of the medical organisation during natural disasters are :-
(a) To prepare the staff and institutional resources for optimal performance in an emergency situation of certain magnitude.
(b) To make the community and other counter disaster agencies aware of the capabilities, execution and benefits of the medical disaster plans.
(c) To establish security, traffic control and public information arrangements.
The medical role during a disaster incident includes
(a) Sending Mobile Medical Teams / Quick Reaction Medical Teams / First aid teams to the site of the disaster.
(b) Providing First Aid and Basic Life Support at the site of the incidence (Pre hospital stabilization)
(c) Sorting out the afflicted victims into priorities for evacuation (Triage)
(d) Safe and Speedy transportation from the site of incidence to the location of providing definitive care.
(e) Providing Advance Life Support and definitive care at the hospitals
(f) Provisioning of Rehabilitation Services to the affected individuals
(g) Care of the dead and moribund individuals.
(h) Prevention of Epidemics and other related health hazards (Environmental health management).
(j) Epidemiological and Health-surveillance efforts
(k) Setting up Communication Centres for providing relevant information to the public, community and other agencies.
To carry out the above roles to perfection at the time of a disaster event it is mandatory that all concerned in the medical organization must be aware of their roles and responsibilities. Thus arises the necessity of having a well designed and integrated Disaster Plan. Failure to Plan is Planning to Fail when the event actually happens. Planning provides the opportunity to network and engage all participants prior to the event. It provides the opportunity to resolve issues outside of the “heat of the battle”. Experience tells us that thinking about and planning for disasters is not as painful as having to explain why we didn’t.
Principles of Natural Disaster Plan of a Medical Organisation
The basic principles which form the template of a Natural Disaster Plan are :-
(a) Simplicity – It should be simple and operationally functional
(b) Flexibility – It should be executable for various forms and dimensions of different disasters
(c) Clarity – It should lay down a clear definition of authority and responsibilities and not use too many technical jargons
(d) Concise – It should be suitable for the type of hospital and not be so voluminous that nobody will read it
(e) Adaptability – Although the plan is intended to provide standardized procedures, it should have an inherent scope for adaptability to different situations that can emerge during disasters
(f) Extension of normal hospital working – It should be made in such a way that the plan merges with the normal functioning of the hospital
(g) Practiced Regularly to make it work and to recognize and reduce and eliminate the shortcomings.
(h) Permanent and periodically updated based upon the experiences gained from rehearsals and disaster situations faced
(j) A part of a Regional Disaster Plan.
The key issues involved in any disaster plan are Preplanning, Communications, Co-ordination, Training and Regular practice. Without these elements no amount of technical skills and modern technology can mitigate the sufferings of disaster victims.
Pre-requisites for Disaster Planning
There are certain pre -requisites that require to be deliberated before planning for and managing disaster events. These are briefly described as under :-
(a) Hazard / Vulnerability Analysis: This is based on past experiences and the vulnerability status of the localities that are within the ambit of the administrative and clinical jurisdiction of the health care facility. For example if an area is prone to earthquakes it is important that the hospital building is earthquake proof and the Disaster Plan of the hospital is able to cater to the rescue and relief of the victims of the earthquake. It is also important to remember that Earthquakes, Accidents don’t come with prior notice but Floods, Cyclones do. Pre disaster preparedness in later case can prove to be very useful.
(b) The Role, Responsibilities and Work relationships amongst all the staff of the health care institution must be clarified.
(c) Hospital Capability Analysis: It is also essential to be familiar with the hospital treatment capacity should mass casualties suddenly arrive without adequate prior notice. Generally as a thumb rule the Hospital Treatment Capacity is 3% of total Hospital Beds whereas the Hospital Surgical Capacity in an eight hourly shift can roughly be calculated as under:-
No. of operating rooms x 7 x 0.25
(d) Hospital – Community cooperation in Disaster Planning: This is also an essential precondition and the outside support must be kept on alert and must be signalled to move at appropriate time to be in position in affected area immediately before the arrival of the casualties.
Who Should Make the Hospital Disaster Plan?
This is the next obvious question as to who should be responsible for making a hospital disaster plan. More often than not it is felt that this is the responsibility of the Hospital Administrators only. Well, the hospital administrators do play a major role in framing, coordinating, rehearsing and implementing the disaster plan but no single individual can effectively make the disaster plan of any health care set up since making the plan is a multidisciplinary affair and all disciplines should be involved in framing a plan for the implementation and success of which they are ultimately responsible.
Herein lies the importance of constituting the Hospital Disaster Management Committee (HDMC). The Suggested Membership of this committee is as under :-
(a) Director/Executive Head of the Hospital.
(b) Departmental Heads.
(c) Nursing Supdt./CNO/SNO
(d) Hospital Administrator
(e) O I/C Casualty Services.
(f) Maintenance and Engineering Staff.
(g) Staff Representative.
(h) Representatives from other support services and utility services as required.
Functions of HDMC
It has been commonly said that sitting on a committee is like sitting on a WC. One makes a lot of noise and ultimately drops the entire matter. Well, the function of HDMC goes much beyond this saying. For this committee to function effectively, its role and responsibilities and terms of reference must be clearly laid down. Broadly the role of HDMC is :-
(a) To develop the Hospital Disaster Plan.
(b) To develop Departmental Plans in support of the Hospital Plan.
(c) To plan Allocation of Resources.
(d) To allocate duties to Hospital Staff.
(e) To establish standards for emergency care.
(f) To conduct and supervise Training Programme.
(g) To supervise Drill to Test the Hospital Plan.
(h) To review and revise the Disaster Plan at regular intervals.
Components of Hospital Disaster Plan
The various components of a well thought out disaster plan are enumerated below. These components will vary from one health care institution to other depending upon the capability and capacity as well as the hazard and vulnerability analysis. Notwithstanding this, the components should focus on the following aspects
(a) Efficient system of Alert and Staff assignments.
(b) Unified Medical Command.
(c) Mobilisation of Resources
(i) Medical Nursing, Administrative Staff.
(ii) Medical Stores Supply and Equipment.
(iii) Conversion of useable space into clearly defined areas for Reception, Triage observations and immediate care.
(d) Procedure for prompt movement of patients within the hospital.
(e) Procedures for discharge/referral/transfer of patients including transportation.
(f) Prior establishment of Public Information Centre.
(g) Security arrangements for inpatients, casualties, property of patients and the hospital etc.
(h) Evaluation of Hospital Autonomy in terms of water, electricity, food and medical supplies including gases.
(j) OT utilization planning.
(k) Planning for X-ray, Lab and Blood Bank.
The HDMC is required to prepare a disaster manual which should be crisp, easily understood by all and should contain the details of the mode of execution of the Disaster Plan. The hospital disaster manual is a written statement of the disaster plan which is required to be activated during any type of disaster and is divided into five sections which though not sacrosanct and can be modified according to the needs and requirements but they form the template on which the hospital disaster plan can be prepared and executed. A prototype of the template is given below
Section I :- Introduction
(a) Disaster Alert Code.
(b) General Principles of conduct.
(c) Brief synopsis of total plan.
Section-II :- Distribution of Responsibilities
(a) Requirement and responsibilities
of individuals and departments.
(b) Action cards.
Section-III :- Chronological Action Plan
(a) Initial Alert.
(b) Activate hospital Disaster Plan.
(i) Notify key personnel.
(ii) Activate key Depts.
(iii) Give details of Resource
(iv) Pre-arranged wards/areas for
(c) Formation of a command nucleus
(i) Preferably near the casualty
(ii) Define roles of hospital controller.
(iii) Senior Nursing Officer, Hospital
(iv) Clinical Principles of Management
(vii) Admission of Patients.
(viii) Utilization of supportive services.
(ix) Principles of treatment of
¬Basic Life Support
¬Advance Life Support
(d) Specific problems of Disaster
(i) Clinical Problems.
¬Less, serious patients report first.
(ii) Administrative Problems.
¬Police Documentation Team.
¬Friends and Relatives.
¬Crowd control ® Convergence
¬Press and Media.
¬Disposal of Dead.
Section IV :- Check List Of Personnel And Items.
(a) Designation of overall medical
(b) Establishment of communication
(c) Notification rosters.
(d) Triage centre with Triage Officer.
(e) Personnel Assignments.
(f) Designation of medical teams & areas
(g) Routes of disposal.
(h) Criteria for patient categorization.
(i) Rapid documentation cards
(j) Security arrangements.
(k) Plans for logistics and supplies.
(n) Information booth / Help desk
Section V :- Repeated Rehearsals.
(a) To train
(b) To test performance
(c) To correct weaknesses and deviations.
A brief explanation of the aforementioned template is given in the subsequent paragraphs for the ease of understanding
The introduction should include disaster alert code, general principles of conduct and brief synopsis of total plan. When the alert is given all personnel must report to duty and takeover their assigned jobs. A sample synopsis is placed at the end of this chapter.
Distribution of Responsibilities
(a) Authority and Command Nucleus : A small disaster management committee consisting of
(i) Executive Head of the hospital
(ii) District Health Officer/Civil Surgeon
(iii) Professor of Medicine/Surgery/Officer In Charge Accident and Emergency Services
(b) Action Cards : The duties of each individual and dept are clearly indicated on a “Action Card”. These cards describe in details the responsibilities and the actions to be taken by each and every member of hospital staff starting from hospital administration to stretcher bearers and ward boys. Action card can be carried at all times and/or kept at command centre. If the designated individual proceeds on leave / out of station, then it should be the responsibility of the stand in individual to be aware of his role as per the action card.
Chronological Action Plan
For efficient and effective implementation during a disaster episode the action plan must be listed in chronological order. The salient features of the Action Plan are briefly explained below
(a) Initial Alert :
(i) Source of Alert
(aa) Accident and Emergency department itself
(ab) Through telephones or
(ac) Through authorities like police etc.
(ii) Action to be undertaken. On receipt of information, the concerned person must gather information regarding the place, time and type of disaster incident , the estimated number and type of casualties and the source of communication. He should also have a callback number if possible to remain in constant contact with the reporting personnel. This would help in determining the time available to prepare (response time) for the emergency and the necessary reorganization of hospital services to cope up with the same.
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(b) Activate Hospital Action Plan : The designated hospital staff activates the disaster plan. All the departments and people involved get into readiness to attend to casualties and depending upon the nature and number of casualties, crisis expansion of hospital beds is undertaken, utilizing additional space, by discharge of minor /cold cases and transfer of cases to other hospitals/ health care centres.
(c) Formulation of Command Nucleus : The command nucleus should be formed immediately and located either in or close to the Accident and Emergency department.
(d) Management of Casualties : This deals with
(i) Admission of patients
(ii) Triage and
(iii) Organization of clinical services.
(iv) Further treatment
(v) Collection of information for management and for relatives and media
(e) Hospital Management ; Once a disaster call is made and the hospital control unit established, the mobilization of the hospital services may proceed at the speed required with the minimum loss of time. Usually a number of designated areas will need to be created.
An initial reception area acts as the first point of triage in the hospital and distributes patients to appropriate treatment zones. In addition, the initial reception will involve the documentation for casualties.
The most experienced surgeons available should be responsible for triage. If staffing permits, assign specific members to care of each patient needing urgent attention. Ambulatory patients and those needing less urgent care should go to a separate area to await treatment at a convenient time.
A large well lit open space is needed for effective resuscitation. Patients are prepared for surgery if required or sent to the wards as soon as their condition stabilizes. A senior “anaesthetist” is the best choice to supervise resuscitation and to prepare, with surgical advice, the theatre schedules.
(iii) Operation Theatres
Strict sorting is necessary to avoid blocking theatre space with patients with trivial injuries and who happen to arrive first. They may be treated in a separate theatre (Minor O.T) or at convenient times when other major problems are dealt with. Treatment in wards or Intensive Care units will need to be organized to follow initial care in accident department and the theatres.
Proper radiology assessment is needed for the correct management of many casualties. Strict triage for radiology should be practiced by staff to avoid bottleneck in radiology department and over use and failure of X-ray machines or shortage of X-ray films. Portable X-ray machines will be preferred in orthopedic O.T. and image intensifiers sh
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