Correspondence
Medical Response after an Earthquake
N Engl J Med 1996; 334:1746-1747June 27, 1996
- Article
To the Editor:
In their article on the medical disaster response after an earthquake (Feb. 15 issue),1 Schultz et al. propose an early response by volunteer physicians who have been given supplemental training and are equipped with medical backpacks. These physicians are intended to function in “solo-treatment areas” for the first hour or so. Such a force could readily offer sophisticated first aid and possibly manage a few more advanced field resuscitation techniques. It is unrealistic, however, to expect such personnel to be able to locate, reach, and resuscitate, let alone extricate, victims trapped in collapsed structures.
The likelihood that entrapped victims will survive declines precipitously after 24 to 48 hours.2,3 For that reason, the Federal Emergency Management Agency developed the Urban Search and Rescue Task Force system. The self-contained, 62-person teams in the system include specialists in technical and canine search techniques, hazardous-materials management, structural engineering, heavy rescue (extrication requiring heavy equipment), and confined-space medicine. These teams can be deployed by ground or air transportation within six hours, along with 30,000 lb of equipment. Yet even with the elaborate resources and staffing of an Urban Search and Rescue Task Force, it can require many hours to reach and extricate a heavily entrapped victim.4,5
Most lightly entrapped survivors are rescued by uninjured bystanders,2,4,5 and these survivors can be treated effectively by solo physicians. A heavily entrapped victim, however, cannot be extricated in a safe and timely fashion by any number of solo providers. Yet Schultz et al. seem to envision their early responders in this role, since the backpacks include supplies for field amputations, fasciotomies, and treatment of the crush syndrome (but, curiously, no protective gear). Moreover, the compartment and crush syndromes generally require four or more hours to develop. . . .
The concept of a distributed first response to an earthquake is attractive, but even an army of sophisticated solo-treatment providers cannot offer the multifactorial response needed to locate, treat, and extricate heavily entrapped victims.
5 ReferencesEdward S. Bessman, M.D.
Johns Hopkins University School of Medicine, Baltimore, MD 212241
Schultz CH ,Koenig KL ,Noji EK . A medical disaster response to reduce immediate mortality after an earthquake. N Engl J Med 1996;334:438-444
Full Text | Web of Science | Medline2
Noji EK ,Kelen GD ,Armenian HK ,Oganessian A ,Jones NP ,Sivertson KT . The 1988 earthquake in Soviet Armenia: a case study. Ann Emerg Med 1990;19:891-897
CrossRef | Web of Science | Medline3
Pretto EA Jr ,Safar P . National medical response to mass disasters in the United States: are we prepared? JAMA 1991;266:1259-1262
CrossRef | Web of Science | Medline4
Barbera JA ,Lozano M . Urban search and rescue medical teams: FEMA Task Force system. Prehospital Disaster Med 1993;8:349-355
Medline5
Barbera JA ,Cadoux CG . Search, rescue, and evacuation. Crit Care Clin 1991;7:321-337
Web of Science | Medline
To the Editor:
The proposal by Schultz et al. for a medical disaster response contains some forward-thinking concepts, but their discussion nevertheless omits some essential parts of a modern disaster plan. First, there is no plan for communication among medical providers in a disaster; in fact, there is no plan to notify providers of their role in a disaster (i.e., where to go and where to find supplies). Not all disasters are as obvious as an earthquake. We need to be able to notify people when a disaster like that in Bhopal, India, occurs. Since so many physicians, nurses, and pharmacists now carry beepers, there should be a national system of disaster notification through the beeper network. All that is needed is a generator-powered, emergency backup system that will use standardized transmission frequencies already in place.
Second, it is not enough to have a backpack with bandages. A provider participating in the system should have a battery-powered mobile telephone to communicate with the command and control center. Even better would be laptop-computer systems with digital communication by radio or satellite dish to provide information about the status of a disaster in the most rapid manner. Third, each provider must have prearranged, visible identification — an identification badge, as well as a jacket or jumpsuit. If a local home or office is to be used as a triage point, it must be visible to the community. Special flags or beacons are essential. Identification badges allow the police or National Guard to transport bona fide providers to hospitals or medical-relief stations without delay.
It is unwise to have providers use their own automobiles, which will merely add to traffic jams and confusion in a disaster. The transportation of medical and nursing personnel is not a trivial matter, as those who remember the Northeast's blizzard of 1978 and its effect on staffing in hospitals will confirm.
Finally, the disaster-response system must provide for the resupply of aid stations. To save costs, hospitals keep a decreasing inventory of supplies on hand — at most, usually a one-month supply of drugs and dressings to meet normal demand. Because of regulations, the amount of narcotics on hand may be as small as a normal supply for one week. The principal warehouses for and distributors of medical supplies must be identified and included in a disaster plan, as well as the means to deliver supplies by air or ground to treatment centers.
Jeffrey L. Kaufman, M.D.
Baystate Medical Center, Springfield, MA 01199Author/Editor Response
The authors reply:
To the Editor: It is axiomatic that communication systems fail in moderate-to-large-scale earthquakes. In the Loma Prieta (San Francisco), Northridge, and Kobe temblors, communication was disrupted in spite of attempts to prepare for such eventualities.1-3 All forms of telecommunication currently available commercially are vulnerable to disruption, including cellular phones and satellite devices.2 A combination of totally portable satellite systems, hand-held radios, and radios operated by amateurs (ham operators) offers hope for the future, but how they will be integrated and who will pay for them remain unresolved. Therefore, any medical-response plan designed for immediate implementation after a major earthquake must function effectively in the absence of an intact communication system.
The Medical Disaster Response Project is designed for just these circumstances. After a large earthquake, physicians and other health care workers with previous training report to the nearest disaster-medical-aid center, where supplies are already available. The location of every station is marked on a map carried by these persons in their cars.
The transportation of victims is problematic. With the potential for 100,000 casualties and a limited time for treatment, no jurisdiction will have access to enough ambulances or other vehicles to transport all patients. Ideal or not, current options must include private automobiles.
Dr. Bessman suggests it is unreasonable to expect volunteer medical professionals to participate in both search-and-rescue activities and resuscitation of victims. We agree. As we note in our article, untrained bystanders rescue 85 to 95 percent of ultimate survivors in the first 24 hours. Medical providers should concentrate their efforts on stabilizing victims.
We believe urban search-and-rescue teams are a critical resource; in the Oklahoma City bombing, they arrived within hours. In a large earthquake, however, in which roads, bridges, and airports have been severely damaged, the teams may be unavoidably delayed for 24 hours or longer. Moreover, as Dr. Bessman states, it requires many hours to reach and extricate victims. These inherent delays mean that most victims will have been rescued or will have died by the time outside help can arrive in force. As James Lee Witt, the director of the Federal Emergency Management Agency, has said, “It will be the local responders at the scene who will make the difference between life and death for so many people.”4
4 ReferencesCarl H. Schultz, M.D.
Harbor–UCLA Medical Center, Torrance, CA 90509-2910Kristi L. Koenig, M.D.
Alameda County Medical Center, Highland Campus, Oakland, CA 94602Eric K. Noji, M.D., M.P.H.
Centers for Disease Control and Prevention, Atlanta, GA 303411
Martchenke J ,Rusteen J ,Pointer JE . Prehospital communications during the Loma Prieta earthquake. Prehospital Disaster Med 1995;10:225-231
Medline2
Friedman E . Coping with calamity -- how well does health care disaster planning work? JAMA 1994;272:1875-1879
CrossRef | Web of Science | Medline3
Shiono S ,Mukainaka S ,Kai T , et al. Medical supports by emergency medical centers in Osaka following the Great Hanshin earthquake. Prehospital Disaster Med 1995;10:S10-S10 abstract.4
Witt JL . National disaster plans crucial: local practitioner readiness essential! Acad Emerg Med 1995;2:1021-1022
CrossRef | Web of Science | Medline
- Citing Articles (2)
Citing Articles
1
Yoram Wolf, Yaron Bar-Dayan, David Mankuta, Aharon Finestone, Erez Onn, David Morgenstern, Nahshon Rand, Pinhas Halpern, Carlos Gruzman, Paul Benedek, Giora Martinovitz, Arieh Eldad. (2001) An Earthquake Disaster in Turkey: Assessment of the Need for Plastic Surgery Services in a Crisis Intervention Field Hospital. Plastic and Reconstructive Surgery 107:1, 163-168
CrossRef2
Stephen H. Thomas, Tim Harrison, Suzanne K. Wedel, Daniel P. Thomas. (2000) H ELICOPTER E MERGENCY M EDICAL S ERVICES R OLES IN D ISASTER O PERATIONS. Prehospital Emergency Care 4:4, 338-344
CrossRef
