Xiang-Hui Li, MS; Jing-Chen Zheng, MD, PhD

Transcription

1 MILITARY MEDICINE, 179, 8:913, 2014 Efficient Post-Disaster Patient Transportation and Transfer: Experiences and Lessons Learned in Emergency Medical Rescue in Aceh After the 2004 Asian Tsunami Xiang-Hui Li, MS; Jing-Chen Zheng, MD, PhD ABSTRACT This descriptive study aimed to present experiences and lessons learned in emergency medical rescue after the 2004 Asian tsunami in terms of transportation and transfer of patients and coordination of medical rescue forces. After the tsunami, numerous rescue institutions and international organizations rushed to Aceh province to aid in the rescue work. To coordinate various aspects of medical rescue efforts, an airport-based joint patient transfer center was developed. Within the framework of the joint transport center, rescue teams, militaries, and international institutions worked together to jointly triage, rapidly treat, and transfer patients. As members of the Chinese International Search and Rescue team, we were involved in the rescue efforts in the joint patient transfer center, and treated and transferred a total of 217 injured patients, the majority of whom were triaged as level II, followed by level III, and level I. The top three diseases were trauma/wound infection, respiratory system disease, and digestive system disease. The airport-based joint patient transfer center provided an efficient mechanism for successfully coordinating various aspects of the medical rescue efforts to transfer patients. Large-scale air transport, available health resources, and effective triage criteria also played an essential role in patient transportation and transfer. INTRODUCTION Postdisaster medical rescue is often a complex issue involving multiple dimensions, and rescue organization is particularly critical for achieving the best results. 1 Transportation and transfer of patients and coordination of medical rescue forces are important components of postdisaster medical rescue work. 1 The success of disaster relief activities relies on efficient patient transfer and transportation. Because of the unique nature of every disaster, postdisaster rescue efforts, including patient transfer and transportation, are often complicated by distinct challenges. Reviewing the experiences and lessons learned about emergency medical rescue after a unique disaster event can help improve the ability to respond to future natural disasters. On December 26, 2004, a massive undersea megathrust earthquake occurred with an epicenter off the northwestern coast of Sumatra, Indonesia. With a magnitude of 9.0 and duration of nearly 10 minutes, the earthquake triggered a series of devastating tsunamis along the coasts of more than 10 countries bordering the Indian Ocean, resulting in one of the deadliest natural disasters in recorded history. 2 The quake and resulting tsunami killed more than 280,000 people and displaced more than one million individuals. 2 Indonesia s Aceh province was the hardest hit area, suffering the highest losses and mortality. 3 According to the figures publicized by the Indonesian government 1 year after the tsunami, the disaster left 38,786 persons dead, 129,775 missing, and 504,518 displaced in the Aceh province. The massive casualties resulting from this colossal disaster necessitated the involvement of large-scale emergency General Hospital of Chinese People s Armed Police Forces, Beijing , China. doi: /MILMED-D medical services (EMS), and the plight of the affected people prompted a gigantic international humanitarian response. 2 In the days following the tsunami, many countries dispatched rescue teams to the affected areas. The Chinese government sent the Chinese International Search and Rescue (CISAR) team to Aceh to provide international humanitarian assistance and EMS. As members of the CISAR team, we were involved in the rescue efforts in Aceh and witnessed the entire emergency medical rescue process. Because of the unique geographical location and poor weather and road conditions caused by this unprecedented event, postdisaster medical rescue efforts presented some serious and distinct challenges. The 2004 Asian tsunami relief efforts have highlighted the value of several unique models in the area of public health. 4 In addition, the Aceh experience with patient transportation, transfer, and medical rescue coordination shows some distinct features. This descriptive study aims to present experiences and lessons learned in emergency medical rescue after the 2004 tsunami in terms of transportation and transfer of patients and coordination of medical rescue forces. METHODS Major Challenges Posed by the Disaster The province of Aceh, located at the northwestern tip of Sumatra, is surrounded by water on three sides and consists of numerous islands. The tsunami caused extensive damage to roads and bridges, resulting in the paralysis of land transportation. The destruction of boats, together with seismic waves causing continuous aftershocks and high winds, significantly hampered sea transportation. A large number of victims were scattered in the tsunami-struck cities, countries, and islands. The shortage of food, drugs, and drinking water, MILITARY MEDICINE, Vol. 179, August

2 contamination of water resources, massive destruction of health and medical infrastructure, and limited sanitation facilities made it very difficult to carry out antiepidemic measures to prevent the outbreaks of communicable diseases. 4 The death toll from the disaster kept increasing following the tsunami, and there was a major conflict between the urgent need for rescuing survivors and the lack of efficient rescue pathways. Emergency Medical Rescue Responses In the days following the tsunami, over 400 rescue institutions and international organizations rushed to Aceh province to aid in the rescue work. Rescue institutions from Australia, Germany, Belgium, and other neighboring Asian countries were among the first to arrive at disaster-hit areas. 5 Militaries equipped with field hospital facilities from many countries also reached the province of Aceh. Nongovernmental organizations, such as the United Nations and World Health Organization, and various international organizations, such as the International Immigration Association and Australian Agency for International Development, also actively took part in the rescue work. 5,6 However, the suddenness of the disaster and the rapidly changing environment made the initial international assistance response disorderly and inefficient. 6 At the early stage of the rescue work, rescue personnel had to stay at the Banda Aceh airport because of transport barriers. Thousands of tons of rescue materials piled up at the airport and could not be distributed effectively. Meanwhile, disasterstruck residents who desperately needed these rescue materials were scattered either on islands far from the airport or in the inaccessible countryside. Under these circumstances, air relief became the only effective rescue pathway. Air Rescue Under the coordination of the On-Site Operations Coordination Centre, which is part of the United Nations Office for the Coordination of Humanitarian Affairs, and the Local Emergency Management Agency, the American military, Indonesia, Australia, and Singapore provided several dozens of air freighters and helicopters for long-distance air rescue. Various types of airplanes took off from and landed at the Aceh airport continuously to enable injured and sick patients to access to the best, fastest, and safest medical treatment. Air freighters such as the American C-130 and the Russian Ilyushin Il-76 carried relief resources, and passenger planes carried refugees from Aceh to Medan and Jakarta. Helicopters were used to carry injured and sick patients from inaccessible islands and refugee camps to the Aceh airport and then evacuate them to available hospitals for treatment. 7,8. C-5 and C-17 transport aircrafts were deployed to transfer relief materials, military personnel, and equipment; CH-47 transport helicopters were used to transfer patients and provide EMS to victims; SH-60B helicopters were modified to make them more suitable for disaster rescue and humanitarian assistance. Nearly 60 helicopters provided by the American military performed 2,200 flying tasks, shuttling from U.S. warships and other staging areas to hard-hit towns and villages. Food, drugs, sanitation equipment, and other relief materials were transported by air to inaccessible disaster-struck areas or islands, and injured patients and disaster-hit residents were transported back to the airport. Air rescue was the most effective rescue method in disaster-struck areas, saving a total of 1 million victims. Airport-Based Joint Patient Transfer Center Because of the unique challenges posed by the disaster, an airport-based joint patient transfer center, which consisted of the American military, U.S. Agency for International Development, local Aceh hygiene departments, International Organization for Migration (IOM), and many other international rescue institutions and agencies, was developed to transport and transfer victims and effectively facilitate medical rescue activities. 9 The American military, Indonesian government, and Australian and Singaporean air forces deployed helicopters to transport injured patients from inaccessible refugee camps and islands to the Aceh airport. The U.S. Agency for International Development and IOM were responsible for building a transfer station to accommodate victims. Responsible personnel unloaded wounded patients out of helicopters safely and quickly with stretchers to the transfer station where triage was conducted. Medical workers and volunteers from China, America, Australia, and other countries provided medical aid services. After simple triage and rapid treatment, the victims were transferred to various nearby medical institutions. Essentially, the working procedure of the joint patient transfer center consisted of triage, rapid treatment, and transfer. Triage The whole triage process for each patient was conducted in 5 minutes or less. The triage procedure consisted of a preliminary examination (1 minute) and a reexamination (3 minutes). The Simple Triage and Rapid Treatment (START) system 10 was adopted in the preliminary examination, with particular attention paid to wound status, respiration, perfusion, and consciousness. The basic condition of each wounded patient was roughly assessed, and patients with life-threatening conditions who could be saved by immediate treatment were separated and given emergency treatment. After life-threatening injuries were identified and treated to minimize further harm, a reexamination was conducted to identify other less serious injuries and perform a more detailed physical examination. During the reexamination, the symptoms and a simple medical history were acquired from the patients to determine the proper treatment and transport means. Triage separated the injured into 4 levels: I, II, III, and IV. 10 Level I patients were seriously injured victims that needed immediate treatment. Level II patients were those who had injuries that could not lead to death within hours, 914 MILITARY MEDICINE, Vol. 179, August 2014

3 and their treatment could be postponed up to several hours. Level III patients could walk by themselves and did not require emergency transfer. Level IV patients were dead or were critically injured and would die even if they received prioritized emergency treatment or transfer. Rapid Treatment On the basis of the triage categories, treatment priority was decided upon. Critically injured patients were given early emergency treatments, which included cardiac monitoring, oxygen uptake, establishment of infusion channels, and cardiopulmonary resuscitation. Patients with life-threatening conditions who could be helped by immediate treatment or transfer were given the highest priority. Before transportation vehicles arrived, on-the-spot treatments could be given, including wound management, changing dressings, fixation, anti-infection treatment, symptomatic treatment to arrest vomiting, and providing tranquilizers and analgesia. Transfer Before transferring seriously or critically injured and sick patients, a second round of triage was carried out to assess the injury, decide upon the transport priority, and perform some necessary treatments such as spinal immobilization. At the early stage, injured and sick patients could be directly transferred to Medan hospital, which is approximately 300 km away from Aceh and which remained intact after the disaster. On January 2, 2005, with the influx of large number of refugees and patients, Medan hospital was unable to accommodate any additional injured or sick patients from Aceh. The patients had to be transferred to Fakina Hospital, General Hospital, or Army Hospital in Banda Aceh (approximately km away, and a minute drive). Medical staff accompanied the transferred patients for the entire journey and carried out the transfer with doctors from local hospitals. Involvement of the CISAR Team in Emergency Medical Rescue The CISAR team arrived at the Aceh airport at 12 o clock (p.m.) on January 1, 2005, and established a mobile field hospital on the same day to carry out EMS. The next day, upon an invitation by the coordinator of the joint patient transfer center, the CISAR team began to take part in the treatment and transfer of injured and sick patients. The CISAR team deployed a medical group daily from January 2 to 8 to provide EMS. The patient transfer station of the IOM could initially fulfill triage of 12 to 20 wounded people simultaneously, but could no longer work normally with the growth in the number of patients detained at the airport. To overcome this problem, the CISAR team established another transfer station, which could accommodate 4 to 8 wounded patients simultaneously. This greatly relieved the EMS pressure at the joint patient transfer center. The CISAR transfer station consisted of 3 workers: a team leader who was responsible for overall coordination and external contact; a doctor who was responsible for triage, early emergency treatment, and transfer; and a nurse who was responsible for nursing work, including infusions, blood pressure measurements, and cardiac monitoring. RESULTS From January 2 to 8, 2005, the CISAR joint patient transfer center treated and transferred a total of 217 wounded or injured patients. Their ages ranged from 86 days to 79 years, with most patients aged between 43 and 67 years. The majority of patients were triaged as level II (70.97%), followed by level III (22.58%), and level I (6.45%) (Fig. 1). There were no level IV patients. The top three diseases were trauma/ wound infection, respiratory system disease, and digestive system disease (Fig. 1). DISCUSSION The destructive impact of the 2004 Asian tsunami was enormous. Over the past decade, we have participated in rescue efforts for many global disasters, such as the 2003 Bam (Iran) earthquake, 2008 Wenchuan (China) earthquake, 2010 Haiti earthquake, 2010 Yushu (China) earthquake, and 2010 Pakistan floods; however, we were most deeply impressed by the Aceh rescue because of the grandness of the rescue scenes, the coordination of rescue efforts, and the merging of cultures. Although several years have passed, the rescue scenes in Aceh are still fresh in our minds. The context-specific rescue efforts in Aceh have highlighted several unique features in emergency medical rescue. 4 Our experiences in emergency medical rescue during this tsunami hold many useful lessons for similar situations elsewhere in the world and can help plan future disaster responses. An Airport-Based Joint Patient Transfer Center Provides an Efficient Mechanism to Transfer Patients Requiring EMS After the tsunami, rescue institutions from various countries poured into the Aceh airport without coordination, making FIGURE 1. Distribution of triage levels and diseases in the patients. MILITARY MEDICINE, Vol. 179, August

4 rescue activities disorderly and inefficient. 6 In addition, traffic in Aceh was paralyzed, with railways interrupted, bridges destroyed, roads damaged, and sea transport hampered. Fortunately, the airport remained intact, and transfer of patients by air became the most effective means of transportation. Thus, the airport became the center for collecting and distributing relief resources and transferring patients. Under these circumstances, an airport-based joint patient transfer center was developed to coordinate disparate institutions and facilitate the transport and transfer of patients. Within the framework of the joint transport center, rescue teams, militaries, and numerous international institutions worked together and jointly transported the injured, with each organization playing to its strengths and avoiding duplication. This collaboration made full use of relief resources, greatly improved patients access to health care, and enhanced patient throughput. Transport, triage, treatment, and evacuation are among the most important components in disaster medical relief. 1 The airport-based joint patient transfer center incorporated these components and formulated a highly efficient medical relief model for transferring patients from disaster-hit areas by helicopters to the airport and then by land to hospitals. After helicopters arrived at refugee camps and on islands that were scattered around the disaster-hit region, seriously or critically injured patients were given priority for air transport. At the airport, those injured or sick underwent triage and rapid treatment. Patients were then sent to nearby hospitals with the best medical capabilities using land transport. This land-air-land medical rescue approach worked well at each stage and made full use of the relief resources. Patients benefited greatly from the integrated transfer and transport scenario, coordinated specialty teams, and swift care. The airport-based joint patient transfer center represents a promising postdisaster medical relief model, especially when means of transportation other than air are not available or impracticable. Large-Scale Air Transport Has an Irreplaceable Role in Patient Transportation and Transfer in Emergency Medical Rescue Transport of acutely injured and ill patients by air is currently an integral part of health care systems. 11 Because the time from injury to medical intervention is the most important factor affecting patient outcome and air transportation is the fastest transport means, aircrafts have played a crucial role in previous emergency medical rescue activities. 1,12 With regard to mass casualty situations, many injured people were evacuated by air in the 1988 Armenia earthquake, the 1995 Kobe (Japan) earthquake, and the 2008 Wenchuan earthquake. 13,14 The most remarkable feature of air transport in the Aceh rescue was its massive scale. An unprecedented number of aircrafts was delivered in the rescue, and they were of diverse types, including air freighters, passenger planes, and helicopters. Large-scale aeromedical transport should be an essential component of emergency medical rescue work after mass-casualty disasters. 15 Another remarkable feature of air transport in the Aceh rescue efforts was the use of many different types of helicopters, including CH-47 and SH-60B. Helicopters provided the most effective and fastest means of transporting patients and relief materials in the Aceh rescue efforts because they could reach most areas, bypass difficult terrain, and provide rapid point-to-point transfers. 16 The adoption of helicopters effectively solved the traffic bottleneck in disaster-hit areas and provided victims with the help they greatly needed. Equipment of helicopters could be an objective in future disaster rescue work to improve EMS. Over the past several decades, the important role of air transport in mass casualty situations has been recognized. 1,13,14 However, because each disaster is a unique event, there is still controversy over the optimal use of aeromedical resources. The Aceh rescue, together with past disaster response efforts, has highlighted several best practices for air transport of patients in mass casualty situations. First, the use of large commercial airports and military air resources (see below for details about the role of the military in patient transport) can greatly assist in large-scale emergency response. Second, the combination of fixed wing (for long-distance transportation) and rotary wing aircrafts (for short-distance transportation) has become a routine relief operation after mass disasters. Third, the identification of transportation nodes and networks is an important aspect of patient transportation. 17 The Aceh airport as an important transportation node played a central role in patient transport. Fourth, rapid and direct transportation of patients from the disaster area to a rear hospital represents a new trend in patient transport. In the Ache rescue and the 2008 Wenchuan earthquake, a threelevel transportation system was used 1 ; however, a simplified two-level transportation system was used in the Hurricane Katrina, the 2003 Bam earthquake in Iran, and the 2010 Yushu earthquake. 1,18,19 This simplified system ensures that the patients can get timely medical treatment. 1 Finally, the importance of treatment facilities in the aircraft has also been emphasized in previous mass rescue activities. 1,20 Because of the complicated injuries of wounded patients, air transport of patients without discrimination may aggravate some injuries and even endanger lives. 21 Care during transportation provides a solution to the condition. In this regard, a model like the U.S. Air Force s Critical Care Air Transport Teams provides the best practice to reduce adverse consequences of critical illness and critical care delivery. 22 Despite many advantages of air rescue, it is not absolutely risk-free in terms of the safety of aircrafts and appropriateness for transporting certain patients. 23 The authors witnessed the crash of an American SH-60B helicopter because of mechanical failure near Banda Aceh on January 10, Luckily, no casualty was reported. In April 2005, an Australian Sea King helicopter with nine soldiers crashed in the tsunami rescue. In 2008, there were 11 major air medical crashes, 916 MILITARY MEDICINE, Vol. 179, August 2014

5 which resulted in 32 fatalities. 23 In addition, it can be dangerous to transport seriously and critically sick patients by air, as the patients conditions might change at any time. High altitude might affect patients physiologically and psychologically. 21,24,25 Therefore, rescuers and patient caregivers must be cognizant of the advantages and disadvantages of air transport and weigh its safety risks against its benefits. The Efficiency of Patient Transport and Transfer Largely Depends on the Availability of Health Resources and Establishment of Effective Triage Criteria When a large-scale disaster happens, the number of patients grows rapidly, and there is usually an enormous lack of medical facilities and rescue personnel for seriously or critically sick patients. Because of the massive destruction of hospitals and limited medical resources in Aceh, the number of patients requiring EMS far outweighed the hospitals medical capabilities. Some patients had to be transferred a second time to other hospitals. Because of these factors, patients failed to get immediate medical care or effective treatment. In future rescue activities, the managing staff of rescue organizations should ponder how to make best use of various medical resources to treat the most patients. Improvised facilities, such as mobile field hospitals, may be developed to divert patients and prevent the patient transfer center from becoming overwhelmed. 26,27 Because limited medical resources cannot immediately and simultaneously meet the needs of large numbers of people for EMS, the key point in disaster rescue is to prevent the limited medical resources from being used to treat minor injuries rather than serious and deadly injuries. 24 Triage aims to improve working efficiency when extremely limited medical resources are available to cure more patients 28,29 It allows for the identification of patients who need advanced medical care, sets priorities for evacuation, and determines the mode by which patients should be transported. 21 There are two types of triage: simple and advanced. START, used in the Aceh rescue, is one of the most widely used simple triage systems in the world. 10 Despite its many advantages, the START system is also associated with a number of limitations, including imprecise goals, a lack of measured of outcomes, a lack of consideration for resource availability or victim survival probability, and a lack of differentiation among trauma types. 30 These limitations can cause subjective and inconsistent triaging. In particular, triage decisions should be made considering the availability of resources, because both overtriage and undertriage will lead to ineffective use of medical resources. 31 Because air transport was the most effective transport modality in Aceh, overutilization of air transport caused by overtriage would make transport unavailable for subsequent victims who had more appropriate needs for this transport modality. 8 Although START ensures acceptable levels of undertriage, it incorporates a substantial amount of overtriage. 10 For this reason, two rounds of triage were carried out in the Aceh rescue to determine transfer priority based on the injury condition before patients were finally transferred. Our work at the joint patient transfer center took place 8 to 14 days after the disaster. By this time, most seriously injured patients had died in remote and inaccessible places, which was why there were no level IV patients identified at the patient transfer center. Because of the heavy destruction of living facilities, environmental pollution, lack of food and clothes, and extremely poor hygiene, wound infection and even septicopyemia occurred among patients, and the incidence of acute respiratory infection and acute gastroenteritis grew drastically. As a result, some level III patients turned into level II patients because of the lack of prompt medical treatment and aggravation of illness, which resulted in the maximum number of level II patients. Given that START incorporates a substantial amount of overtriage and is useful in prioritizing transport of the most critical patients, 10 it might not have been the most suitable for or fully effective in the Aceh rescue (only 6.45% of patients were triaged as level I). In this regard, context-specific triage criteria for use in the classification of tsunami casualties should be developed. The Military Has a Crucial Role in Patient Transport and EMS When reviewing the Indonesian tsunami rescue several years after the event, what impressed us most was the active participation of military forces from various countries. Around 40,000 people from the military or civil defense of 35 countries participated in the rescue, and they provided 75 helicopters, 43 fixed winged airplanes, and 41 warships. The military forces significantly improved the rescue abilities and saved thousands of victims lives. Taking the American military as an example, the Asian tsunami rescue was by far its largest nonwar military operation. Approximately 16,000 U.S. military personnel were deployed at the height of the relief effort, and more than two dozen U.S. ships and over 100 aircrafts were used. The 17 helicopters on the Lincoln carrier performed 1,747 relief tasks and transferred a great deal of food, medicine, and water to the victims, as well as transporting over 3,000 victims and international rescue workers. 7 Because of the military s rapid mobilization and arrival; timely and forceful organization; leadership to meet specific needs; and transportation, engineering, and logistics support, the military can perform many rescue activities that civilian organizations cannot achieve effectively. 8 In fact, the military has been the primary force in many medical rescue efforts in the world. 32,33 Experience managing combat casualties by appropriate patient triage and rapid transport has been demonstrated to be useful in optimizing the outcomes of mass casualty events. 34 These facts suggest that disaster rescue should be an important noncombat operation of modern militaries in peace time. MILITARY MEDICINE, Vol. 179, August

6 There Is Still Room for Improvement in Patient Transportation and Transfer Despite the involvement of various types of airplanes and other vehicles, transport inconvenience was still a major practical problem in patient transportation and transfer in Aceh. The vehicles used to transport victims were sometimes delayed 2 to 3 hours, whereas the patients were detained at the patient transfer center. Because of road destruction, the long distance between hospitals and the patient transfer center, and the time spent handling victims, it usually took quite a long time (>1 hour) to transfer patients to hospitals. In addition, trucks, rather than ambulances, were used to transport patients, which increased medical dangers on the way. All of these factors indicate that there is still room for improvement in patient transportation and transfer. Guidelines for postdisaster patient transport and transfer might be designed to optimize transport systems, enhance transport coordination and organization, and improve patient handling to overcome these problems in future rescue activities. CONCLUSION The natural disasters that have occurred over the past 10 years have caused huge losses of life and property. 1,35 Although we cannot prevent disasters from happening, we can do our best to help the victims. By summarizing the experiences and lessons learned in emergency medical rescue after the 2004 Asian tsunami, we can improve our rescue capabilities in future disaster rescue efforts. The main lessons learned from the Aceh experience with patient transportation and medical rescue coordination are as follows: (i) An airport-based joint patient transfer center represents an efficient model for successful coordination of various aspects of medical rescue efforts to transfer patients. (ii) Disaster victims can benefit greatly from the incorporation of a large-scale air transport program into rescue protocols. (iii) Effective improvement of the availability of health resources by triage or other methods can efficiently improve patient transport and transfer. (iv) Disaster rescue should be an important noncombat operation of the modern military in peace time. (v) A substantial improvement in emergency medical rescue outcome can be achieved by more rapid and efficient patient transportation and transfer. REFERENCES 1. Zhang L, Liu X, Li Y, et al: Emergency medical rescue efforts after a major earthquake: lessons from the 2008 Wenchuan earthquake. Lancet 2012; 379: Morrow RC, Llewellyn DM: Tsunami overview. Mil Med 2006; 171: Doocy S, Rofi A, Moodie C, et al: Tsunami mortality in Aceh Province, Indonesia. Bull World Health Organ 2007; 85: Tarantino D: Asian tsunami relief: Department of Defense public health response: policy and strategic coordination considerations. 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