Download Anesthesia Management for Earthquake Disasters: Lessons from

Anesthesia Management for Earthquake Disasters:
Lessons from the May 2008 Earthquake in Sichuan, China
Faping Tu, M.D.* † Bin Chen, M.D. *, Tai Xiang, M.D. *, and Weike Tao, M.D.†
*Department of Anesthesiology, Affiliated Hospital of North Sichuan Medical College,
Nanchong, Sichuan, People’s Republic of China.
†Department of Anesthesiology and Pain Management, the University of Texas Southwestern
Medical Center at Dallas, Dallas, Texas.
Short Title: Anesthesia during Earthquake Disasters
Corresponding Author:
Weike Tao, MD
Department of Anesthesiology and Pain Management
University of Texas Southwestern Medical Center at Dallas
5323 Harry Hines Blvd
Dallas, TX 75390-9068
Phone: 214-648-4840
Fax: 214-648-2229
email: [email protected]
Reprints: Not available
Financial Support: None
Conflict of Interest: None
ABSTRACT
Surgery and anesthesia after earthquakes are performed with extremely limited equipment and
supplies. Civilian rescue workers may not handle victims properly before arrival of medical
personnel, and their efforts may compound the victim’s injury. Aftershocks pose a special threat
to patients and operating room personnel. Easy-to-carry local anesthetics and anesthetic supplies
will prove extremely useful for on-site surgery, as well as helping hospitals in the days and
weeks after earthquakes. Earthquake and disaster education should be part of the anesthesia
curriculum, especially in areas prone to earthquakes.
Earthquakes occur most frequently in a handful of countries, such as Japan and China, but they
can strike almost anywhere, including California and Alaska.1 While most earthquakes are
minor, major earthquakes can be associated with overwhelming numbers of casualties, requiring
acute rescue efforts from a large number of civilian and medical rescue workers. Published
reports from earthquake areas have provided information on various aspects of earthquake injury
management, including emergency and surgical treatment, as well as outcome analysis.2-7 Our
focus in this article is on the preparation and management of anesthesia during an earthquake
disaster.
On May 12, 2008, an earthquake of 8.0 on the Richter scale struck the most populated province
of Sichuan, China, with the epicenter in the mountainous Wenchuan County. Over 69,000 people
died and more than 374,000 were seriously injured.8 The Chinese government responded to the
earthquake with a rapid movement of aid workers and army troops into the area, and the Ministry
of Public Health joined in the efforts with a nation-wide mobilization of physicians and other
healthcare workers, including over 300 anesthesiologists, to the numerous disaster sites. Upon
arrival, however, surgeons and anesthesiologists found their roles hampered by critical
shortcomings:
1. The quake area encompassing over 170,000 square miles, and many affected areas were
inaccessible to vehicles carrying medical supplies;
2. Some affected areas were close to 10,000 feet in altitude where few airdrops of supply
and rescue troops could be attempted;
3. Most local hospitals and clinics were destroyed;
4. Numerous aftershocks posed a constant threat to patients and operating room personnel in
buildings still standing after the first earthquake;
5. Inadequate diagnostic tools and compromised physical as well as emotional status of
victims hampered the ability of medical personnel to fully assess the severity of injuries;
6. Critical resources for surgery and anesthesia, including electricity, oxygen, basic
monitors, medications, fluids, and emergency equipment were grossly inadequate.
In addition, some rescue personnel had no prior training and experience in handling earthquake
victims, which led to adverse outcomes:
1. Complex injuries: When victims were spotted under rubbles, joy and excitement led to
overzealous pulling and moving of body parts, often resulting in further injury to the
victim;
2. Crush syndrome management: Some victims managed to survive many days under fallen
structures and debris, only to suffer a dramatic death when their limbs were rapidly
released without proper fluid administration;
3. Inadequate anesthetics: While the focus was to bring life-saving equipment and supplies
to the scene, there were not enough supply of basic, effective, and easy-to-carry
anesthetics such as ketamine and local anesthetics, which would have proven far better
than no anesthesia for surgery performed at the scene;9
4. Wound treatment: Rescue workers were anxious to treat contaminated wounds before
large quantities of saline could be obtained. Use of bottled water to wash away dirt and
clots led to more severe bleeding and necrosis of tissues, and led to more difficult
management in subsequent surgery and anesthesia;
5. Foreign aid supplies: Some foreign medical products and supplies could not be properly
used without proper medical labels and inserts in Chinese.
From the rescue efforts in Sichuan, many lessons can be learned which may prove useful for
anesthesiologists and other medical personnel alike in preparing for future disasters:
1. Establish earthquake disaster education and drills: Although many hospitals and
departments have plans for major incidents such as hurricane, fire, flu outbreak, and
bomb threats, little is taught or practiced to prepare for an earthquake, even in areas prone
to earthquakes. Medical schools and training programs need to incorporate earthquake
and other natural disasters into their curriculum, and use of drills or simulation-based
education may be necessary;10-12
2. Learn how to provide anesthesia with limited resources: When an overwhelming number
of victims need to be treated on-site, the best medicine may consist of fluids and local
anesthetics only. These supplies are relatively easy to carry and can be managed by
surgeons and nurses while anesthesiologists attend to other seriously injured victims;
3. Be aware of aftershocks: Earthquakes are rarely single tremors. Immediately after an
earthquake, it is much safer to operate in open space, tents, or temporary sheds than in
remaining operating rooms or hospitals. It is critical to transport patients to hospitals
outside the affected area promptly to ensure timely treatment of more incoming victims;
4. Be prepared to perform regional anesthesia: Even in hospitals in surrounding cities, use
of regional anesthesia was dramatically increased in the days and weeks after the
earthquake.13 Fortunately, Chinese anesthesiologists are very experienced in regional
anesthesia.
The earthquake in Sichuan clearly highlighted the need for disaster preparedness. Training in
“disaster anesthesia” involves education, drill planning, and support from hospital administration
and other professional departments (Figure 1). In earthquake-prone areas, such planning may be
mandatory and updates in “earthquake anesthesia” should be part of the continuing medical
education. Throughout the training, drills, and simulation, the following skills are to be taught:
1. Establish the role of the anesthesiologist in a rescue team;
2. Establish effective communication with other rescue personnel, and if necessary, take
them through a “crash-course” on basic monitoring and management skills to best utilize
anesthesia resources;
3. Transport essential medications and supplies to the scene;
4. Rapidly evaluate vital signs of the injured with limited monitors;
5. Provide basic anesthesia in an adverse environment with limited medications and
supplies;
6. Choose a dose and route of administration for anesthesia/analgesia with limited
intravenous access and inadequate monitors;
7. Update skills in regional anesthesia techniques for limb surgery;
8. Transport injured patients with unstable vital signs and injured organs;
9. Protect the patients and medical staff from aftershocks in the course of anesthesia and
resuscitation; and
10. Identify and avoid complications from rescue efforts or during surgery without adequate
monitoring.
It is also important to realize that, during the course of disaster relief, the location, role, and tools
available to the anesthesiologists may change, and one should take advantage of improving
working conditions.
In conclusion, earthquakes are mostly unpredictable. When they strike densely populated or
urban areas, anesthesiologists will be mobilized as a critical part of the rescue team. Mind and
skill preparations to operate in a harsh environment after major earthquakes should be a critical
component of modern medical education aimed at saving lives, reducing complications, and
providing humane care to earthquake victims.
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Figure 1: Organization of hospital preparedness program