Disaster management--are we ready?

AN Supe 
 Dept of Surgery, Seth G S Medical College and KEM Hospital, Parel, Bombay, Maharashtra.

Correspondence Address:
A N Supe
Dept of Surgery, Seth G S Medical College and KEM Hospital, Parel, Bombay, Maharashtra.

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A disaster is defined as a sudden massive disproportion between hostile elements of any kind and the survival resources that are available to counterbalance these in the shortest period of time[1]. In. mass casualty situations, demands always exceed the capacity of personnel and facilities. Mass casualties such as sailing ship disasters and war casualties have occupied the attention of surgeons since the 17th century. In the last few years, there has been an increased incidence of civil disasters; the spectrum of possible catastrophes has also & dramatically increased as a result of an increasingly technologically sophisticated society. Disaster preparedness plans must encompass the possibility of nuclear accidents, hotel and high-rise fires, terrorist attacks, aviation accidents, bomb blasts, riots and industrial explosions as well as natural calamities such as floods, epidemics drought and cyclones[2],[3],[4].

The emphasis of medical management shifts from individualised treatment to standardised therapy for disaster victims with the aim of providing maximum benefit to a maximum number of salvageable patients. "A successful medical response to multi- injury civilian disasters, either natural or man-made, dictates formulation, dissemination and periodic assessment of a contingency plan to facilitate the triage and treatment of victims of the disaster[5].

During the last 10 years varied terrorist activities have become increasingly common as expressions of the opinions of extreme political groups, especially in India. In the four months (December 1992 - March 1993) itself in Bombay, we have witnessed two widespread riots and a series of terrorist bomb blasts. Though most of the hospitals in Bombay managed the medical problems associated with these disasters efficiently, an analysis of the situation is presented so that this may form the basis for future planning in disaster preparedness.

::   Magnitude of the problem

The city of Bombay witnessed three major disasters in the last four months. The riots, which started on December 7, 1992 and January 7, 1993 were essentially due to violence between two communities. The wounds encountered included stab injuries, head injuries and chopper injuries in the initial phase and bullet injuries to various parts of the body thereafter. These riots lasted for 3 and 4 days respectively. The third disaster followed a series of bomb blasts on March 12, 1993 at various locations in the city of Mumbai. The number of victims in the riots and bomb blasts are listed in the [Table:1]. During the riots, patients were brought in steadily over a period of 3-4 days while in the bomb blasts, a large number of patients and corpses arrived at the hospitals within a 2 - 3 hours period.

::   Transportation and crowd control

Transportation is of vital importance when coping with such disasters. Ambulances must be requisitioned for transporting the seriously injured to hospitals. During the riots in Bombay ambulances were not available to pick up the casualties; police jeeps and personal cars had to do this job. This delay at times resulted in late initiation of the management of a few patients. In contrast, during the bomb blasts, there was an effective ambulance service, which was supplemented by the public transport systems, such as buses and taxis, which transported the casualties rapidly to the various hospitals. During the riots, due to the fear of bullet injuries crowds were not a source of concern. On the other hand during the bomb blasts, rapidly growing crowds consisting of curious bystanders and over-enthusiastic paramedical and medical personnel occasionally hampered a rapid triage. However, these well meaning people ultimately aided in providing treatment to a large number of patients.

::   The triage system

Triage (French:sorting) means categorization and distribution of casualties, which establishes priorities and proper location of treatment. The triage must be carried out at the disaster site as well as in the hospital. In the recent disasters, triage was non- existent at the disaster sites. In the hospitals, though there had been no prior planning or ciffils, triage was conducted by a senior medical officer posted in the Emergency Room.

Three factors are essential to an efficient triage system: identification, communication and transport[6].

1. Identification: Casualty categorization not only includes initial evaluation of the injuries but assigns a value to the injury - relative to the mass casualty situation. A simple method of identification, such as a tag banded to a victim, transmits information regarding patient identification. In our hospital widely utilised categorizations[7] were employed. Patients were classified according to their therapy needs viz. 1) requiring only outpatient treatment. 2) requiring indoor admission and expectant treatment, 3) needing immediate exploration and 4) capable of tolerating delayed treatment Sections for each group were temporarily created. Subsequently, these patients were managed effectively by different groups of doctors.

2. Communication: The communication system though sub-optimal, was useful in rapid notification of all the necessary support groups. There was no effective communication between the disaster site, transport vehicles and referral facilities such as the hospitals.

3. Transport: There was a relative shortage of transport trolleys in transporting patients to operation theatres and wards.

Adequate resuscitation and prevention of further complications are essential principles in the non-operative management of mass casualties. Proper splinting and immbolisation of injuries of the spine and the extremities allowed definitive treatment to be done at the appropriate elective time. Operative therapy was directed towards life-saving procedures only. Adequate debridement of contaminated wounds and control of haemorrhage were the considerations in the initial surgical management.

::   Medical supplies and equipment

The hospitals were not equipped with supplies and equipment for exclusive use only in mass disasters. Though emergency ward supplies were depleted quickly, the hospital administration reacting promptly, provided adequate quantities of intravenous lines, solutions, dressing supplies, airway equipment, anaesthetic agents, drainage tubes, urinary catheters, nasogastric tubes, splints and drugs.

::   Special considerations

A relative deficiency of senior medical officers existed during the riots due to non-availability of transport and the fear that prevailed. Residents however, manfully shouldered the responsibility of patients. The demand for anesthesia in a disaster situation is often overwhelming in terms of personnel and time utilization. The Department of Anaesthesia however put in yeoman service. Efficient blood bank services supported the mass casualty management obtaining additional blood and blood products and processing emergency blood and blood products and processing emergency blood donors including HIV testing.

All disaster plans must provide for temporary morgue facilities. In our hospital the morgue capacity being exceeded, the Anatomy department mortuary was used for storing dead bodies. Photographs of the deceased were displayed on the Notice Board. A relatives' guidance cell in front of the Emergency Room, efficiently managed by medical students and non-clinical department staff members, catered to this essential need.

::   Mass casualty planning: recommendations

Though most of the public hospitals in Bombay quite effectively managed these disasters, the following recommendations, based on experiences gained during these disasters, need to be considered while planning for such mass casualty situations.

Hospital Planning: All hospitals must have a designated disaster committee composed of knowledgeable representatives from medical and non-medical departments. The committee must formulate a disaster plan that is flexible enough to meet the demands of any disaster but is practical in terms of hospital trauma capabilities, location, personnel and equipment. A handbook for ready reference must be prepared outlining this plan. This must be made available at all important locations in the hospital. The handbook should emphasize factors, which help in organising specific teams for a particular disaster. These factors include i) Nature of the problem: riots, gas leaks etc. as the nature of injuries may differ from riots to chemicals explosions. ii) Number of disaster victims: organisation of services depending upon the number of casualties. iii) Period of disaster: bomb blasts and fires are usually one day problems while riots may continue for a few days.

The administration must make food and stay arrangements for staff, preferably at their working places. In situations where the disaster is likely to continue for a few days (eg riots), it is better to prepare a rota of the available personnel. The security and protocol for visiting dignitaries should be planned and organised so as not to disturb the working medical teams. The committee has the responsibility for dissemination and reappraisal of the plan in terms of the community's and hospital's changing needs. The disaster plan must be tested periodically in the form of a drill. The disaster plan director should be a physician or a surgeon experienced in both administration and trauma care. The importance of the triage system and mass casualty management must be emphasised at all levels (i.e. from medical students to senior consultants).

Community planning: Disaster planning is the responsibilty of all sections of the community. The police, fire brigade, civil defence, home guards, press, clergy, industrial groups and community groups must participate in the pre-disaster planning[8]. The community as a whole has the responsibility to teach first-aid to groups in the community who could be utilised in disaster situations. The disaster may involve the normal communication network itself. Two way radio systems and messenger systems must be included in the event of a communication-system failure. It is vital to have communication between disaster site and hospitals, so that the patients can be distributed to various hospitals depending upon their capacity and load. Disasters often potentiate mass hysteria, which limits effective implementation of the disaster plan. The help of various security and police organisations must be recruited to provide medical teams unimpeded access to disaster victims.

::   Conclusions

Reduction in mortality and morbidity in mass disaster can be achieved only by a well organised, concise but flexible pre-disaster situations, to avoid potential chaos at such situations. We need to develop such a plan in order to accurately assess the magnitude of the disaster and make provision for sufficient trained personnel and logistic support to meet the demands of the mass disaster.

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