Disaster Management

JK-PRACTITIONER

Mass Casualty Management - Our Experiences

Farooq Ahmad Jan, Syed Amin Tabish, Mushtaq A. Shaheen, Dharminder Kumar

Abstract Emergency Services have a statutory duty to develop a comprehensive, integrated and flexible all-risk Major Incident Plan (MID) to deal with disasters. At Sher-I-Kashmir Institute of Medical Sciences we often see ballistic trauma, Road Traffic Accidents, agricultural accidents and house collapse victims being rushed to the hospital in large numbers. To meet these challenges a Disaster Plan has been formulated. This study has been carried out to see how actually disaster plan works and to identify deficiencies. A prospective study was carried out in Accident & Emergency department for a period of one-year i.e. from July 2003 to July 2004. Although the management of patients was excellent in the hospital, staff cascading and mobilization needs to be addressed. Out-of-hospital (at site) disaster management is virtually nonexistent in Kashmir. Collaboration and sharing of knowledge, information and expertise beyond the medical realm is imperative in assisting hospitals to expedite appropriate preparedness programme.
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INTRODUCTION Sher-I-Kashmir Institute of Medical Sciences is a tertiary care hospital located in Srinagar and caters to patients from all over the valley. We often see road traffic accidents, mine blast, grenade blast and bullet injury victims being rushed to the hospital in huge numbers. To meet this challenge a disaster plan has been formulated in this hospital. Any incident causing Casualties on a scale which threaten or cause overload of the available resources of the Emergency Medical Services (EMS) or associated system constitutes a major incident1 Emergency Services have a statutory duty to develop a comprehensive, integrated and flexible allrisk Major incident plan (MID) for such an event1 WHO has defined disaster as an event; natural or man-made sudden or progressive, which impacts with such severity that the affected community has to respond taken exceptional measures2 According to Colin Grant, disaster is an unexpected event Authors Affliations: occurrence leading to injury or illness simultaneously to at least 30 people Farooq A. Jan, S.A Tabish, MA Shaheen who will require hospital emergency treatment3 Deptt. Of Hospital Administration Disaster Management implicates different sectors at different times Dharminder Kumar and the need for co-operation and co-ordination among local, state and Deptt.f of Cardiology national agencies is never more apparent than in the case of disasters, hence SKIMS, Soura, Srinagar disaster management necessitates a multidisciplinary approach. Disaster cannot be managed in vacuum. Many agencies have to be integrated into the Accepted for Publication plan to prevent duplication and confusion4 May 2005 A Disaster severity scale has been designed to classify certain disasters. The scale is based on the cause, the effect on the community, the size Corresspondence to of the affected area, and the time needed for relief services to clear the area. Dr. Farooq Ahmad Jan Sher-i-Kashmir Institute of Medical Sciences Another system, potential injury creating event (PICE) has been developed to describe disasters. PICE is designed to identify several aspects of the disaster Soura, Srinagar (INDIA) such as potential for additional causalities, and whether or not available E-mail:Jan_farooq2004@rediff.com. resources are being overwhelmed. Knowledge and the type of injuries and illness caused by a particular disaster are essential for creating strategies to prepare for a proper distribution of necessary supplies, equipment and personnel. If polices and agreements are developed as part of disaster preparedness on international, bilateral and national levels, disaster relief may be more relevant, less chaotic and easier to estimate thus bringing improved relief to the disaster victims.6 Emergency care providers and incident managers attempt to procure and co-ordinate resources and personnel often with inaccurate data regarding the true nature of the incident, needs and ongoing response. In this chaotic environment; new technologies in communications, and Internet, have the potential to vastly improve the
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emergency medical response to such mass casualty incident disasters. In particular next generation wireless Internet and geopositioning technologies have the greatest impact on improving communications, information management and overall disaster response and emergency medical care. These technologies have applications in terms of enhancing mass casualty field care, provider safety, field incident command, resource management, informatics support; and regional emergency department and hospital care of disaster victims7 Recent militant activities have under scored the potential for disaster to generate large number of casualties. Few surplus resources to accommodate these casualties exist in our current health care system. Plans for surge capacity must thus be made to accommodate large number of patients. Surge planning should allow activation of multiple levels of capacity from the health care facility level to the tertiary level. Plans should be scalable and flexible to cope with the many types and varied timeliness of disaster. However resource limitations may require implementation of triage strategies. Facility based or surge in place solution maximize health care facilities capacity for patient during a disaster. When the resources are exceeded, community based solutions

generator and tents. The hospital can also be air-lifted in an air craft to distant places during an emergency. After the tsunami tragedy the process of procuring a mobile hospital in India has been expedited. METHODOLOGY A prospective study was carried out in the Accident and Emergency department of SKIMS for a period of one year (July 2003 to July 2004) in which management of mass casualties reporting to the hospital was studied. Only those incidents were accounted for where number of casualties reporting to the department was ten or above at one time. The management of these casualties was followed right from receiving information about the incident to their discharge of victims from the hospital. The weaker areas of disaster management plan were identified. RESULTS During the period of study we received a number of blast victims, road traffic accidents, bullet injury patients but the number of incidents where number of patients was ten or more than ten happened sixteen times. Only at three instances prior information about the incident was given to the hospital. Message was given ten

S.No 1. 2. 3. 4. 5. 6. 7 8. 9 10 11 12 13 14 15 16 17

Table: I: MAJOR INCIDENTS RECEIVED DURING PERIOD OF STUDY Type of incident No of Patient Nature of Injury No of patients Dead Blast 10 Polytrauma 01 Road Traffic accident 14 Polytrauma Nil Blast 10 Polytrauma Nil Blast 24 Polytrauma 01 brought dead Road Traffic accident 31 -do02 RTA 11 -do01 RTA 14 Head injury 01 RTA 10 Polytrauma Nil RTA 30 -doNil RTA 12 -doNil Blast 17 -doNil Blast 10 -doNil Blast 12 -do01 RTA 24 Polytrauma 03 RTA 13 Polytrauma One Expired RTA 48 Polytrauma 02 Brought dead 03 died in hospital 19-07-004 Blast 16 Polytrauma 01 Expired. Date 4-7-2003 9-7-2003 12-7-003 13-8-2003 6-11-2003 22-11-003 26-11-003 28-11-003 9-4-2004 23-05-004 12-06-004 17-06-004 3-7-2004 8-07-2004 12-07-004 17-07-004 minutes to half an hour before the first patient reached Accident & Emergency. The patients were brought both directly from the site of the incident or referred from other hospitals. Usually a lot of time is wasted as the patients have been shifted to a wrong hospital e.g. a neurosurgery patient being shifted to Bone and Joint hospital. Number of patients loose their lives due to severe blood loss while on the way to the hospital. On receipt of mass casualties or receiving information from authentic source the Resident Hospital Administrator (stationed in the Control Room of Hospital Administration) informs the members of the disaster Committee and activates the disaster plan. Alarm system is non-functional in our hospital and information is given

including the establishment of off-site hospital facilities may be implemented. Selection criteria, logistics and staffing of off-site care facilities is complex and needs to be addressed. Prepackaged trailers may be the answer Mobile hospital is one thing, which can help victims of natural disasters. After the Orissa cyclone and the Gujarat Quake, health ministry had proposed a seven container mobile hospital equipped with latest medical facilities. During tsunami tragedy in Southeast Asia, Russia sent a similar mobile hospital to Sri-Lanka, while Australia rushed a four container hospital to Indonesia. Similar mobile hospitals are operational in Europe, United States, and Newzealand. As per the specification the mobile hospital has an OT, diagnostic, post-operative ICUs, Kitchens, water purifier,
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through intercom ,telephones, (Landlines and mobiles). Emergency cards and case sheets are arranged by medical record technologist in the triage area or even at other places of treatment in the hospital. In none of the disasters tagging of the patients was done. Tagging has been seen to save time and avoid confusion. A separate Disaster Management ward of twenty beds; which is otherwise unstaffed and unoccupied is reserved to meet any major incident. Disaster ward is staffed only at the time of disaster. Beds are also arranged in Emergency Wards by shifting patients from Emergency Department to different specialities. In the disaster plan of the hospital, nursing staff has to be made available to meet any disaster situation round the clock. Nursing has been divided into two groups. First group (Group I) which has to take care of disaster from 10 A.M. to 4 PM are mostly ward incharges who reside outside the Institute. Second group (Group II) which has to take care of disaster from 4 PM to 10 Am are mostly nurses who reside within the campus. In most of the instances patient reported to the hospital after 4 PM. It has been observed that staff mobilization was efficient during the major incidents which reported between 10 am and 4 PM; while as after 4 PM nursing staff had to be deployed from other specialities but none could be mobilized from second group. Main reasons for non-availability of group IInd staff was a). unwillingness of staff to report for duty b). no telephone numbers and address of staff were available c). alarm system was not functional. Doctors usually report for duties both from Accident & Emergency and various other specialties to treat the patients. Consultants on call report for duties whenever called for; although it sometimes takes around half an hour if one has to come from outside campus. Medical supply management is a critical part of both overall preparedness for disasters and effective relief efforts after disaster. Medical supplies for disasters are Stocked in disaster ward. There is even provision of opening emergency store as well as main Store. Standardized list of medical supplies of about fifty items has been made and are kept always available. In Emergency operation theatre usually only one O.R is working and occasionally second O.R is utilised. Number of times patients had to wait as more critical patients were being operated. However many a times main operation theatre was opened and made functional even after 4 pm. DISCUSSION The critical component of any disaster response is the early conduct of a proper assessment to identify urgent needs and to determine relief priorities for an affected population9 This component of disaster management has not kept pace with other developments in emergency response and technology. Relief efforts often are inappropriate, delayed or ineffective thus contributing to increased morbidity and mortality. A stratified assessment of needs, identification of unique dangers to first responders, proactive planning; problem solving, informal horizontal

and vertical communication and coping through stress management techniques are focal subject matters.10 Many lives and limbs can be saved if first level care is organized at the disaster site. Medical care at site involves command, control, communication and coordination at the scene of the disaster as well as linkages to definitive care hospitals. A successful disaster response will depend on accurate and relevant medical intelligence and socio-geographical mapping in advance of during and after the event causing the disaster. Out-of hospital disaster management is virtually non existent in Kashmir, although the plan for the same is being laid down in the state on the pattern of having first aide teams, first aide posts and mobile teams. The transportation plan is one of the important issues in disaster management for rescue, relief survey, and assessment. The co-ordination with various authorities for requisition of transport in disaster event is a part of the plan. Unfortunately ambulance service net work is in infancy in Kashmir. Ambulances have been attached with the first aide teams (one ambulance for five first aids teams) and first aide posts (one for two first aide posts) in the plan being laid down. For maximal efficiency hospitals need to fully coordinate the influx and transfer of patients with out of hospital rescue services as well as with other hospitals. Each hospital has to immediately deploy its operational center, which will manage and monitor the hospital resources and facilitate coordination with the relevant Institutions11 A study in U.S. identified over crowded Emergency departments (84%) and lack of available beds (83%) as the most vulnerable area in mass causality management Causality volume management was never a problem during our study but if the number of casualties is huge it can tax your resources. Disaster drills are an effective way to test hospitals preparedness for real life disasters but an extensive amount of coordination and time is necessary to have a successful drill with a large number of victims. It is not realistic to believe that a drill can be perfectly planned and practiced therefore each drill provides another opportunity to improve on past experience13 Disaster drill was once performed in the hospital during last 3 years. CONCLUSION Out-of-hospital disaster management is virtually non-existent in Kashmir valley. Proper pre-event planning and mechanisms for resource co-ordination are critical to the success of a response. Although the management of patients was excellent in the hospital there is scope for improvement. Staff cascading and mobilization needs to be addressed. It needs adequate personnel consideration to enable effective functioning. Tagging of patients should be made a routine as it will avoid confusion when the number of casualties is huge. Real challenges are to provide medical care when number of causalities far exceeds capacity of hospitals. Collaboration and sharing of knowledge, information and expertise beyond the medical realm is imperative in assisting hospitals to expedite appropriate preparedness programme.
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