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Presented by:
DR.M.FOUJIYA BEGUM,B.H.M.S., I YEAR MBA HOSPITAL MANAGEMENT ENROLLMENT NUM: 5420900006
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Incident : Disaster management, during Railway accident
Date & Time of incident: 08.05.2009 ,3.30 hrs
Description of incident: In the early hours of 08.06.2009,it was reported that Guruvayur express head had collided on into the the Rockfort express has taken place in the which left more than 800 people injured and 256 dead. 103 of the injured and 46 dead were received at Local government medical college Hospital on 02 and 03 may 2009 within a period of about 36 hours. Although a few hours prior information about the arrival of mass casualties was received the sudden influx of such a large number of casualties pushed the entire hospital services to perform beyond themselves in order to manage this disaster.
Action taken: Immeadiately 5 ambulance complete with ICU facility ,3 doctors and paramedics were dispatched to the accident site. In the mean time hospital staff were asked to be on the alert and beds were readied to receive casualty. Pharmacy was alerted for keeping free stock of medicine.
Management of disaster: Patients were identified by names, age and sex .and relatives were informed accordingly Case sheets of each patients were prepared as per the format and was tagged along with the patients bed. Documents for completing police formalities were prepared.
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Brought dead patients (black band) were sent to mortuary .Local government medical college was contacted for further action on the bodies and completing formalities of autopsy and handing over the bodies to victim’s relative. A emergency room was set up at the reception hall to accommodate relatives of the patients and was equipped with seating arrangements and provision for drinking water. 2 nos of dedicated staff assigned to PR duties were entrusted with keeping the relatives updated with patients condition.Also a experienced doctor was called in to sooth the relatives.All personal belongings of the victims were handed over to relatives. Arrangements were made to control the crowd with the help of local police. All the patients had been given first aid at the site of accident by the local medical resources. In addition one surgical team of medical college Hospital went to the accident site to organize the evacuation of casualties. All the cases were received at a special reception center for first aid and documentation. Each case was seen on arrival by a surgeon and allotted priority in the usual manner 1. P-1 cases requiring immediate resuscitation and urgent surgery (these included open intraarticular fractures) 2. P-2 cases requiring possible resuscitation and early surgery including dislocations and open fractures. 3. P-3 for all other cases. In addition special priorities were allotted for spinal and eye injuries.
Resuscitation was carried out along with a quick primary survey and continued in the operation theatre/acute wards as indicated. All cases with open wounds were given tetanus prophylaxis and antibiotics. 4
Table 1
Table 1 : (Triage) PRIORITY
No of
PERCENTAG
CASES
E
Priority-1 Polytruma
12
11.6%
Thoracic injuries Open intra articular fracture Priority-2
31
30.01%
Priority-3
55
53.59%
Special priority
05
04.95%
Acute dislocations Open fractures Others
Cervical spinal injury Dorsolumbar injury
Subsequently the injuries were regionalized. Life and limb saving surgeries were carried out as per priority already allotted. Later the complete nature of injuries were determined and secondary procedures carried out. Injuries requiring treatment at specialized centers were identified and evacuated to appropriate centers.
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Some of the patients arrived in a shocked state because of multiple injuries, airway obstruction, massive bleeding or other trauma requiring urgent resuscitation and early surgery. Patients were provided uninterrupted intensive therapy in severe trauma cases following operations that have suffered critical hypotension or hypoxia preoperatively or intraoperatively. There were no delayed operations or premature interferences. Diagnosis and treatment were occurring simultaneously.
Anaesthesia was administered and maintained despite poor patient status and staffing, sometimes without the benefit of supportive laboratory and previous medical data. There were high incidence if critical events like often lengthy operating procedures, multiple, serial or simultaneous diagnostic or therapeutic procedures. Four patients required ventilatory support and one of them required ventilation for ten days. All the patients were successfully weaned off the ventilator.
Results A total of 149 cases were received in a period of about 36 hours, these included 46 dead. Out of the injured there were 99 males (96.1%) and 04 females (03.89%). Of the 103 injured, 72 cases (70%) were Army personnel, 09 (08.7%) were from Assam Rifles, 06(05.8%) each from Air force and CRPF. There were 07 civilians and three cases from other paramilitary forces. All the injured were traveling in the leading compartments of the two trains.After triage the distribution of cases were as per Table-1.A total of 17 units of blood transfusion were given. No single case required more than 04 units of blood transfusion.Regional distribution of cases is given in Table-2. Table 2 : Regional distribution of injuries 6
s.no 1 2 3 4 5 6 7 8
Region Multiple superficial injuries Lower limb injuries Upper limb injuries Thoracic injuries Dislocations Head, neck & spine injuries 08 Polytrauma Major lacerations
No of cases 68 33 17 14 09 08 05 04
A total of 149 active procedures were carried out during the course of management of the accident victims.The various interventions are listed in Table-3 (Surgical procedures/interventions). There were 40 major injuries to the lower limbs in 33 cases. These included 32 fractures,07 dislocations and one case of anterior compartment syndrome in the leg.
All the seven cases of open fractures of the tibia including one case of double segmental tibial fracture were managed with wound debridement and external fixators to begin with. All 07 dislocations of the hip were reduced under general anaesthesia and managed with skeletal traction after ensuring concentric reduction. Most of the displaced fractures were managed with open reduction and internal fixation if closed treatment was not satisfactory. Fractures of the humerus predominated in the upper limb injuries. One case had bilateral open fractures of the humerus with neurological complications in the right side, however he recovered fully with conservative management after repeated debridements.
Table 3 : Surgical interventions S No. SURGICAL INTERVENTION
No
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1 2 3 4 5 6 7 8 9 10 11
POP application Suturing of lacerations Closed reductions Wound debridements ORIF (Open reduction internal fixation) Tracheostomy External fixators Ventilatory support Amputations Exploratory laparotomies Skeletal tractions
43 38 20 17 15 01 08 04 02 03 10
There were three cases of closed crush injuries of upper limbs without fractures. There were 2 cases of flail chest among the patients with thoracic injuries, one of which had to be managed on ventilator for 10 days. The 08 cases of head, neck and spinal injuries included 04 (50%) skull fractures, 02 (25%) fractures of the cervical spine.All these cases were managed conservatively.Among the three cases of blunt abdominal trauma,one had an isolated splenic injury requiring splenectomy,the other had combined splenic and hepatic lacerations and the third case had a large retroperitoneal haematoma along with a mesenteric injury. All these cases required resuscitation with IV fluids and blood before surgery.
Missed injuries :In this series there were 06 missed injuries (05.8%).These included one case of fracture olecranon in a case of splenic rupture. Three cases of fractures of the clavicle were missed in cases of polytrauma, and malleolar fractures were missed in 2 cases. All the missed injuries were discovered after the patients returned for review after visiting their homes with fresh complaints.
Outcome:
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Sixty-seven cases were discharged within 15 days of admission. Six cases were discharged between 15 days and 2 months and 29 cases required hospitalization beyond 2 months (these were cases of open/complicated fractures). Two cases of traumatic paraplegia were transferred to spinal cord injury centers and 2 cases of comminuted central fracture dislocations were transferred to joint replacement centers for total hip replacement. Three cases of grade 3 open tibia fractures required full thickness skin cover before definitive orthopedic procedures. Two cases required major amputations (one above knee and one below elbow). One case of fracture dislocation C4-C5 died within hours of admission.
Discussion: All the patients had been given some sort of first aid at the site of accident by the meager medical resources that could reach the site. The effectiveness of such treatment was doubtful. In fact it was only delaying evacuation. This makes us rethink the effectiveness of pre clinical emergency management, fiction or fact? Study results obtained in trauma patients indicating that total pre hospital time, including scene time, is correlated to patient outcome have led to the conclusion that at the scene treatment by emergency physicians may be dispensable.
Unusual patterns of injuries observed • The high number of casualties received in a short period of 36 hours • Extrication problems were acute being a railway accident and was responsible for some of the unusual pattern of injuries. • The high incidence of grade 3 open tibial fractures and the use of external fixators • The unusually high number of dislocations of hip
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• The three cases of closed crush injuries of upper limbs (All had complete motor loss in upper limbs without sensory impairment and their subsequent spontaneous recovery) • The two cases of ARDS • Burns and penetrating injuries were conspicuous by absence.
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