Medical Aspects Of Disaster Management Health And Social Care Essay

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.

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.

DISASTER STATISTICS

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.

Disaster defined

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.”

Natural Disasters

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

¬Volcanic Eruptions

(b) Natural phenomenon at the earth’s surface

¬Landslides ¬Avalanche

¬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.

(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

b) Documentation

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.

(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.

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)

(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.

(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.

(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.

(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.

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

Mobilisation.

(iv) Pre-arranged wards/areas for

casualties.

(i) Preferably near the casualty

reception.

(ii) Define roles of hospital controller.

(iii) Senior Nursing Officer, Hospital

Admin

(iv) Clinical Principles of Management

of Casualties.

(v) Reception.

(vi) Triage

(vii) Admission of Patients.

(viii) Utilization of supportive services.

(ix) Principles of treatment of

casualties.

¬Basic Life Support

¬Advance Life Support

¬Definitive Treatment

(d) Specific problems of Disaster

Management.

(i) Clinical Problems.

¬Less, serious patients report first.

¬Contaminated casualties.

(ii) Administrative Problems.

¬Documentation.

¬Police Documentation Team.

¬Communication.

¬Friends and Relatives.

¬Crowd control ® Convergence

effect.

¬Voluntary workers.

¬Patient’s Property.

¬Press and Media.

¬Disposal of Dead.

Section IV :- Check List Of Personnel And Items.

(a) Designation of overall medical

authority.

(b) Establishment of communication

network.

(d) Triage centre with Triage Officer.

(e) Personnel Assignments.

(f) Designation of medical teams & areas

of operations.

(g) Routes of disposal.

(h) Criteria for patient categorization.

(i) Rapid documentation cards

(j) Security arrangements.

(k) Plans for logistics and supplies.

(l) Records.

(m)Evacuation system.

(n) Information booth / Help desk

Section V :- Repeated Rehearsals.

(a) To train

(b) To test performance

A brief explanation of the aforementioned template is given in the subsequent paragraphs for the ease of understanding

Introduction

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

(iv) Matron

(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.

(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.

(i) Reception

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.

(ii) Resuscitation

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.

(iv) Radiology

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 should be used in O.T. if available.

(v) Wards

To increase the capacity of hospitals a surge of additional beds for newly arriving casualties is required to be made by way of discharging elective cases, discharging stable recovering patients, not admitting nonemergent cases and by converting waiting / nonpatient care areas into makeshift wards.

(vi) Blood Transfusion

(aa) Initial replacement of blood volume can be carried out by using plasma-expanders.

(ab) Patients having more than 9.0 gm% Hb should not be given blood.

(ac) Blood is a scarce commodity. Freshly collected blood has to be tested for HIV, Hepatitits B etc. This requires additional facilities and time.

(ad) In most of the cases plasma-expanders will suffice, exceptions being riots and major accidents with surgical trauma. Hence, exact policy to be used with respect to blood collection and storage should be set out in the disaster plan. Utilization of services of local blood banks should be explored in advance.

(vii) Workload

Major disasters can produce situations in which staff works round the clock for long hours under greater pressure. The time of continuous working by any member should be limited by supervisors of the units to a period acceptable for efficient function and the rosters amended as necessary.

(viii) Training

Disasters strike without warning and have been known to recur, particular in the context of waves of urban violence. Training to cope with disasters is thus always needed. The objectives of training are to familiarize all staff concerned with overall strategy of the accident plan and with their individual roles. In the training some parts of the plan need to be tested frequently. A disaster management drill in parts may also be carried out and deficiencies can be identified and solved before full scale exercises are undertaken.

(ix) Evaluation

A system of evaluation must be built into any disaster plan to detect any deficiency in the planning and training and ensure that the responses are sufficiently flexible to meet the variety of needs found at disasters.

Managerial Issues in Disaster Management

The managerial issues that are likely to arise in any disaster situation may either be related to clinical aspects or else the administrative aspects.

(a) Clinical Issues

Clinical issues involve the triage of the mass casualties which arrive at the hospital, the non-serious patients which arrive earlier than the various other more needy patients and demand attention, the crisis expansion of emergency services. These and such issues should be considered and planned in advance while formulating the disaster plan of the hospital and district.

(b) Administrative Issues

For proper execution of disaster management a disaster management team should be formed under the chairmanship of disaster control officer who should be a senior hospital administrator. Administrative issues involved are :-

(i) Documentation : Proper documentation on previously structured forms should be done to save time. The unconscious patient and those dead on arrival may pose some problems. Medico-legal documentation should be carried out for these. A photograph with a digital camera and fingerprint impressions of the victim will help in subsequent identification. The documents may be computerized, one to be kept with medical records, second with Accident and Emergency department, the third with Public Relations Officer and one may be sent to police/district collector for revenue records in case the question of compensation arises in future. Each patient should be tagged on arrival and a case sheet given. The daily status reports of casualties and deaths with their post mortem reports or discharges should be recorded. At the time of discharge, a modified discharge card, with the photograph and thumb impressions of the victim may be provided, so that the identity of the victims can be established later. One copy should also be kept in medical records

(ii) Police Documentation : This may be assisted by Public Relations Officer and other staff not involved in medical care.

(iii) Communications : Telephone lines should be kept functional. Additional lines with STD facilities and restricted numbers for priority messages should be installed with the help of telecommunication authorities. Such emergency lines are permissible, desirable and should be available. The communication should be maintained round the clock and all messages to be written down in the log book in details for follow-up. Wireless services with police assistance and hotline with the collector can also be used in emergency. Fax/Internet services should be used for asking help about drugs equipment/appliances as detailed specification and quantities can be given on fax/internet and there is no chance of confusion which can occur as in telephonic conversation. Couriers may also be kept in readiness for dispatch.

(iv) Friends and Relatives : The anxious, excited friends and relatives want to know the welfare of their kith and kin and hospital authorities should calm them down, console and given them all possible details from time to time from information booth. List of patient may also be displayed with their ward location. The number of relatives attending the patients should be kept at minimum, as this adds to already crowded space and also creates problem in giving emergency care. In disasters like earthquakes where the patients and relatives have lost everything the question of giving food and clothing to these attendants also arises.

(v) Crowd Control : Large crowds of curious people gather in hospital premises and even in reception and treatment areas. They should be controlled, evacuated and only one person with authorized passes be allowed to enter hospital. There should only be one entry guarded by the police. This is very important these days from the point of security and safety.

(vi) Involvement of Voluntary Workers : The requirement of voluntary workers and their disposition should be decided by the hospital administrator and if these are not required, they may be politely told that they will be called when required by the hospital. No organization should be shown favour as others will be hurt. The contact numbers and names of contact persons of these NGOs should be kept.

(vii) Blood Donation Activity : There is usually over response to disaster and lots of people rush to donate blood. Blood donation camps can be arranged as and when blood is required. A list of volunteers and contacts may be kept ready. Additional storages capacity for blood has to be created. HIV and other lab testing is also to be arranged.

(viii) Donation of foods, clothes, drugs etc : Similarly, the response of donation of food materials – cooked food, drugs etc. should also be regularized and controlled as many times the food and the raw materials for preparation of food go waste. The medicine samples of various kinds and drugs which are not wanted are also donated in assorted quantities. This creates problems in inventory, storage, utilization as well as quality control. It has been observed and experienced that sub-standard drugs or even near expiry of expired drugs have been donated. Unsolicited donations should not be encouraged.

(ix) Patient’s property : The normal procedure of listing every single item of patients’ property is not practicable in disaster. A large polythene bag should be keep separately for keeping the property of each patient admitted with identification tags in side. It can later be sorted and listed in the wards. Care should be taken to see that valuables and cash are not pilfered.

(x) Press and Media Services : There should be only one spokesperson of the hospital to interact with the press and media. People should be discouraged to give interviews and their personal opinions, as it can create confusion and mislead the lay people and even authorities.

(xi) Ambulance Services : Ambulance vehicles of the hospital should be well maintained and should be in functional order. Additional vans can be requisitioned from nearby hospitals and social organizations. These are to be kept under control of one person, stationed in control room, who would be responsible for allocation and authorization of the trips. The drivers and attendant must be sitting in the ambulance vans all the time.

(xii) Emergency Lighting & Electricity supply : Arrangement for additional lights in triage area, treatment areas, and maintenance of continuous supply of electricity to X-ray dept , O.T., ICU and blood bank should be ensured. Generators, if not already present should be installed immediately. Reception area and approach road for ambulances should be well lighted.

(xiii) Disposal of Dead : The arrangements for prompt disposal of dead should be made, since at times, the hospital mortuary may not be able to cope up with the large number of dead bodies and which may pose public relations and public health problems. An alternate morgue area should be identified. A holding area for relatives should also be identified and manned by a social worker who will stay with the members. The patients brought dead on arrival should be tagged with a disaster tag and attempts should be made to identify the afflicted individual. Appropriate paper work to this effect must be done.

(xiv) VIP Visits : As far as possible, these should be avoided during first few days as it interferes with hospital work and entails additional security problems It involves emergency personnel with non-productive activities. Later on also, visits by various political or social organization or their spokesmen should be discouraged or arranged to suit hospital convenience and not theirs.

(xv) Teams of Doctors, other professionals and Good Samaritans who are more than keen to help: The word should be passed that unless asked for or appealed such teams should not on their own rush to the site as it hampers rescue work and many times they have no work and get dissatisfied. Most often such teams arrive without adequate briefing, preparation and equipment to be of any help and these good Samaritans more often than not become a liability rather an asset.

Phases of Organisation for Disaster management

Depending upon the location and magnitude of the disaster, the primary or the first level of care is generally organized at the disaster site with a view to provide immediate relief and first aid to the afflicted individuals

The organization of medical relief involves three distinct facets:-

(a) Pre – Hospital care Phase

(b) Hospital care Phase

The Pre-hospital care phase primarily refers to management of the afflicted individuals at the site of the disaster incident, their transportation to appropriate hospital and continued care and comfort during the phase of transportation. The essential components of Pre hospital phase are:-

(a) First Aid teams and /or Mobile Medical teams that are required to be dispatched to the site of the disaster.

(b) On site Treatment and stabilisation

(c) Triage at site that is sorting out of casualties on the basis of their clinical needs which shall be discussed later in the chapter

(d) Transportation to selective care facility. The type of transportation would depend upon availability, capacity and suitability

The hospital or the definitive care phase at the receiving hospital involves:-

(a) Reception of the transferred patients

(b) Carrying out a revised triage

(d) Formulate second stage diagnosis, emergency room treatment, intensive care followed by

(e) Definite diagnosis and treatment.

The post hospital recuperation and rehabilitation phase continues for a long period and may even last for years.

Organisation of Medical Care at Disaster Site

Medical care which can be effectively organized at disaster sites involves some important aspects of organization and staffing :-

(a) Command and Control

(b) Communication

(d) Triage Team

(e) First Aid Team

(f) Mobile Hospital

(g) Evaluation and Casualty clearing team.

Principles of Mass Casualty Management

Disaster medicine is a mass and multiple trauma medicine and it is not different from ordinary medicine, the distinguishing feature is its method of application and primary concern for yield and efficiency. Some types of disasters usually result in a large number of casualties which are beyond the routine handling capacity of the health care system. Application of principles of mass casualty management helps meet the demand of a large number of people. The principles of mass casualty management are universal and can be applied in any mass casualty situation natural of manmade.

(a) Doing the best for the most within the available resources.

(b) Triage is inescapable through out the chain of treatment.

(c) Graded care of casualties, first aid life saving measures, preparation for evacuation, primary surgery and definitive treatment.

(d) First aid measures carried out at the earliest assumes life saving significance.

(e) First aid at the scene of disaster must be limited to monitoring and restoring vital functions.

(f) Simple and standard therapeutic principles.

(g) The casualty must be conditioned or treated so that the degree of urgency is lessened.

Triage

Before we conclude a word about triage since this has been often repeated in the text and needs to be understood as it forms the clinical basis for management of casualties/victims of any disaster event. The meaning of Triage is to sort or sieve.

The basic aim of triage is to ensure that each and every afflicted individual is attended to at the right time with the right treatment at the right place by the right physician / surgeon.

The casualties are sorted out by allocation of various categories / priorities which are briefly stated below :-

(a) Priority I /Category I/ T1 casualties : Immediate resuscitation and treatment : Severely injured victims who can be saved if they receive appropriate stabilization, transportation and treatment immediately. To quantify TI / PI cases refer to those casualties who require immediate life saving interventions ie advance life support in one hour and / or primary surgery within two hours. ( Colour Coded Tag – RED)

(b) Priority II / Category II / T2 casualties : Urgent but less serious cases who can be transported and treated after the most serious have been attended to. These victims will require surgery or other interventions in two to four hours. ( Colour Coded Tag- YELLOW )

(c) Priority III / Category III / T3 casualties : Minimal Treatment / Delayed treatment : Walking wounded who can often be attended in small group and if ambulances are in short supply can be transported by other means. This also refers to the casualties whose treatment can be delayed for a period greater than four hours.( Colour Coded Tag – GREEN)

(d) Priority IV / Category IV / T4 casualties : Expectant . In a disaster event causing very large number of casualties this category may include moribund cases or so severely wounded that even immediate care would be inadequate to prevent death. These casualties are those afflicted with injuries that are so severe that they are less likely to survive and their treatment may compromise the treatment of more needy patients with greater probability of survival if given immediate care ( Colour Coded Tag – BLUE)

Tagging is a commonly used method to indicate priority for the purpose of evacuation and treatment. Various types of tags are in vogue. Each patient must be identified with tags stating their name, age, sex, place of origin, triage category, diagnosis and initial treatment given.

The colour coding commonly used for Triage Purposes is as under :-

(a) Priority I – Red

(b) Priority II – Yellow

(d) Priority IV – Blue

(e) Dead – Black / White

The suggested procedure for assigning scientific priority in the hospital is depicted below

(a) Step I – Calculate the Glasgow Coma Score (GCS)

Eye Opening Verbal Response Motor Response

Spontaneous 4 Oriented 5 Obeys Command 6

To Voice 3 Confused 4 Localises 5

To Pain 2 Inappropriate 3 Pain Withdraws 4

None 1 Incomprehensible 2 Pain Flexes 3

No Response 1 Pain extends 2

No Response 1

(b) Step II – Calculate the Triage Sort Score

X Y Z

GCS Respiratory rate Systolic BP

13 – 15 4 10 – 29 4 90 or more 4

9 – 12 3 30 or more 3 76 – 89 3

6 – 8 2 6 – 9 2 50 – 75 2

4 – 5 1 1 – 5 1 1 – 49 1

3 0 0 0 0 0

Triage Sort Score = X + Y + Z

(c) Step III – Assign Priority

12 = PRIORITY 3

11 = PRIORITY 2

10 or less = PRIORITY 1

(d) Update Priority based on clinical judgment and response

Remember that Triage is the first step in any disaster casualty management plan and is dynamic in nature. It helps in assigning and refining the priorities for casualty management and the Triage Tags / Labels help in indicating the recent / current priority.

SOME MYTHS

Dead bodies are a major cause of diseases.

Please remember that diseases that are not present normally in the affected area will not suddenly occur because of dead bodies. Even if the dead are carrier of diseases they are probably less risk dead than alive. Such myths result in rapid and unceremonious disposal of corpses without proper identification or burial which adds to the suffering of the survivors and also results in diversion of resources that could be used for the survivors.

Things go back to normal in a couple of weeks

The Psychological effects may last a lifetime and hence the need to provide psychological support and facilities to the affected populace after the initial incident has been controlled. It also needs to be understood that the most need for financial and material assistance is in the months after a disaster but forgotten by then.

The medical planners have to incorporate planning for the aftermath of the disaster that will help to reintegrate the population with the normal stream. This would include hygiene and sanitation issues, prevention of likely epidemics and taking care of the psychological effects following the disaster.

Conclusion

Disaster Management involves a host of multi-discipline agencies of which Medical Relief is one of the most important steps. There can be no tailor made Disaster Plan for the hospitals. Each hospital has to evolve its own plan based on the aforementioned considerations, and it has to be revised from time to time as each experience will bring new perspectives.

Finally, it must be understood that a Disaster can occur anywhere and at any time. It has no respect for circumstances. It strikes with suddenness and fury and has a curious tendency of choosing the most inopportune moment. To deal with such sudden influx of a large number of casualties, quantitative extension of Hospital services, operations and safety measures are required.

At the time of a catastrophe, when the casualties are being brought in by the dozens, there is no time for “PLANNING”. That is the time for “DOING”. Perfect Implementation at the time of a disaster incident depends upon regular training and rehearsals with appropriate feedback for further improvements. To mount a credible counter disaster response, the requirement is “Preparedness, not Panic”.

Synopsis

1. Sequence of events on receipt of information.

Receipt of Info A&E Deptt Medical Controller

Alert Code

Hospital Administrator

Coordinator Reception Site

Loading Triage Transportation

of Cars first aid of team and eqpt

Resuscitation to Disaster site.

Documentation.

Evacuation to Hospital.

2. Sequence of events at hospital before receipt of casualties.

Setting up of Control HQ.

Setting up of Reception Point.

Procurement of Medical Supplies, Eqpt., Linen etc.

Planning admission areas and treatment areas.

SNO for detailing of nurses.

O I/C OT will activate his staff.

Chief Coordinator with Departmental Heads will select teams for Medical/Surgical cover and assign their duties.

3. Sequence of Events on receipt of casualties.

Disembarkation and unloading team will be responsible for reception, unloading and documentation.

Triage Team will allocate priorities.

BTD Team – Arrangement for Blood.

Surgical Team – OT, Post OP – ICU.

Hygiene Sanitation Team – Maintenance of Hygiene and Sanitation.

Catering Deptt – Provision of Tea, Coffee, Snacks etc.

Transportation Team

Security/Traffic Control Team.

Requirements for a Disaster Plan

Written : Otherwise it will not be remembered

Simple : Otherwise it will not be understood

Disseminated : Otherwise it will not be available to those who have to implement it

Tested : Otherwise it will not be practical

Revised : Otherwise it will not be up to date

TAKE HOME MESSAGE

Act but with a Plan.

Understand the concepts and Principles.

Take a Practical Strategic Approach.

Rehearse the Medical and Administrative Plans.

Evaluate your Plan at regular intervals.

Involve all medical and relevant non medical resources in the region.

You have enough to do so keep it simple and manageable otherwise nothing will be done.

Do not handle it alone. Build Partnerships.

Colour figs

Fig. 1 : Trauma surgery in progress : MH Bhuj, 2001

Fig. 2 : Improvised operation theatre : MH Bhuj, 2001