Earthquake Relief — The U.S. Medical Response in Bam, Iran
http://www.100md.com
《新英格兰医药杂志》
The magnitude-6.6 earthquake in Bam, Iran, struck at 5:26 a.m. local time on December 26, 2003, while most people were asleep in their homes. It destroyed much of the city. The human and physical devastation was staggering, with 41,000 people presumed to be dead, tens of thousands injured, and nearly all survivors among the original 100,000 inhabitants left homeless. The international response was swift and considerable: ultimately, more than 40 international teams provided search and rescue services, while the Iranians coordinated the evacuation effort locally and nationally. Everyone worked together, motivated not by politics, but by the need to help. Large numbers of injured people were evacuated to hospitals throughout Iran, especially in Tehran and the provincial capital Kerman, since all major hospital facilities in Bam had been destroyed, and their doctors and nurses injured or killed.
Within hours after the earthquake, the U.S. government activated its Boston-based International Medical Surgical Response Team, of which we are members. We were notified late in the evening on Friday, December 26, 2003, and were flying to Iran by Saturday afternoon. In all, 58 health care workers (a double team, composed entirely of civilian volunteers) were sent with a fully equipped, deployable field hospital. Among the physicians on the team were specialists in trauma surgery, obstetrics and gynecology, anesthesiology, primary care, pediatrics, and emergency medicine. Physician assistants and nurses specializing in emergency room, operating room, and critical care were also members of the team, as were paramedics, pharmacists, respiratory therapists, and logistics personnel.
Our team set up the hospital near the destroyed town of Bam in a parking lot adjacent to four other international field hospitals that were run by teams from the Ukraine, France, Spain, and Norway. The austere environment presented formidable challenges to the provision of care. The lack of running water and sewage facilities, the near-freezing nighttime temperatures, and the destroyed infrastructure made caring for our patients and ensuring the safety of the team extremely challenging. That it was possible to do both of these things 24 hours a day attests to the team's commitment to the mission. The Iranians — patients, families, visitors, and government officials alike — remained warm and welcoming throughout our stay, despite the fact that there had been no diplomatic relations between our two countries for nearly 24 years. Over a four-day period, our team provided triage, initial stabilization, and definitive care to 727 people — a small number in relation to the need, but important nonetheless.
The deployable field hospital was used for patients requiring acute care, and three other, smaller tents were used for men, women, and children in need of less urgent care. The surgical cases included two cesarean sections, one appendectomy for acute appendicitis, one gunshot wound of the foot, one hand incision and drainage of an abscess, one completion of a toe amputation, and repair of one degloving injury of a foot (see Figure). In addition to seeing patients with a range of medical conditions, we delivered six healthy babies — happier events that provided everyone with some much-needed hope amid the despair.
Figure. Induction of General Anesthesia in the Operating Room of the Deployable Field Hospital (Panel A) and Cleaning and Preparation of an Injured Foot (Panel B).
The nature of the disaster, which left many people injured or killed, resulted in a shift in our mission, from saving lives to treating many previously untreated earthquake injuries. These cases included trauma to the head and extremities, as well as delayed complications of trauma caused by the earthquake — particularly soft-tissue infections, compartment syndromes, and epidural hematomas. In addition, the large-scale destruction of the public health infrastructure in Bam — as a result of the dust, the cold climate and lack of adequate housing, and the contamination of the water and food supplies — caused serious illnesses in many survivors. Children were particularly affected by the earthquake, in terms of both acute injuries and exacerbations of chronic disease (such as pulmonary, hematologic, and neurologic conditions). An increase in the occurrence of ordinary traumas, such as motor vehicle crashes and injuries, was also seen as a secondary result of the earthquake. Maternal care and neonatal care, especially the latter, represented a substantial portion of the activity in the field hospitals, since so many displaced people were living in tents without adequate heat and water. Psychological trauma from the earthquake was common, often compounding underlying illness and injury. Every single person in Bam suffered devastating loss. Many people lost their entire families, and many children were orphaned.
Disasters follow no rules. The spectrum of threats ranges from natural and man-made disasters (including terrorism) to chemical, biologic, and nuclear weapons of mass destruction. All disasters, regardless of their cause, have similar medical and public health consequences. A consistent medical approach to disasters, based on an understanding of their common features and the response expertise they require, is becoming the accepted practice throughout the world. This strategy, called the mass-casualty-incident response, permits teams from various countries to work together to meet disaster-related needs, despite language and cultural barriers.1,2
The mass-casualty-incident response has four critical medical components: search and rescue, triage and initial stabilization, definitive medical care, and evacuation. Today, the risk of complex disasters, particularly the threat of terrorism and weapons of mass destruction, has increased the need for specialty teams to provide these critical elements of disaster response in austere environments throughout the world. The severity and diversity of injuries, in addition to the number of victims, will be a major factor in determining whether a mass-casualty incident overwhelms the local medical and public health infrastructure.
Medical intelligence is an essential part of an international disaster response. Data on endemic and epidemic illnesses are critical, but an understanding of the cultural and social norms is of equal importance in meeting disaster-related needs. The Bam earthquake was unique in the experience of the U.S. team in that the sex of patients was a consideration in the positioning of the tents. Interpreters are critical assets in all international disasters, and often we did not have enough interpreters to cope with all the patients in the tents. Interpreters were assigned specific areas, such as labor and delivery, so that their skills could be used most effectively.
Trained specialists, however well-intentioned, do not by themselves constitute an effective medical team for a response to international disasters. Critical to a successful medical response to a mass-casualty incident such as the Bam earthquake are important nonmedical elements such as communication, safety, sanitation, and security. Designated members of the International Medical Surgical Response Team are trained to provide these important functions for the team and to serve as liaisons with the appropriate authorities on the scene. This capability greatly facilitated the entire response to the earthquake in Bam, from establishing the field hospital to providing patient care.
As health care professionals, we know that the care of patients is a calling that knows no borders. The Iranians we met displayed great courage and dignity in the face of devastating personal loss. We hope that the support they received from the international community will help to begin the process of rebuilding.
Source Information
From the Department of Surgery, Massachusetts General Hospital and Harvard Medical School, and the International Medical Surgical Response Team — all in Boston.
References
Briggs SM, Brinsfield KH, eds. Advanced disaster medical response: manual for providers. Boston: Harvard Medical International, 2003.
Leaning J, Briggs SM, Chen LC, eds. Humanitarian crises: the medical and public health response. Cambridge, Mass.: Harvard University Press, 1999.(Jay J. Schnitzer, M.D., P)
Within hours after the earthquake, the U.S. government activated its Boston-based International Medical Surgical Response Team, of which we are members. We were notified late in the evening on Friday, December 26, 2003, and were flying to Iran by Saturday afternoon. In all, 58 health care workers (a double team, composed entirely of civilian volunteers) were sent with a fully equipped, deployable field hospital. Among the physicians on the team were specialists in trauma surgery, obstetrics and gynecology, anesthesiology, primary care, pediatrics, and emergency medicine. Physician assistants and nurses specializing in emergency room, operating room, and critical care were also members of the team, as were paramedics, pharmacists, respiratory therapists, and logistics personnel.
Our team set up the hospital near the destroyed town of Bam in a parking lot adjacent to four other international field hospitals that were run by teams from the Ukraine, France, Spain, and Norway. The austere environment presented formidable challenges to the provision of care. The lack of running water and sewage facilities, the near-freezing nighttime temperatures, and the destroyed infrastructure made caring for our patients and ensuring the safety of the team extremely challenging. That it was possible to do both of these things 24 hours a day attests to the team's commitment to the mission. The Iranians — patients, families, visitors, and government officials alike — remained warm and welcoming throughout our stay, despite the fact that there had been no diplomatic relations between our two countries for nearly 24 years. Over a four-day period, our team provided triage, initial stabilization, and definitive care to 727 people — a small number in relation to the need, but important nonetheless.
The deployable field hospital was used for patients requiring acute care, and three other, smaller tents were used for men, women, and children in need of less urgent care. The surgical cases included two cesarean sections, one appendectomy for acute appendicitis, one gunshot wound of the foot, one hand incision and drainage of an abscess, one completion of a toe amputation, and repair of one degloving injury of a foot (see Figure). In addition to seeing patients with a range of medical conditions, we delivered six healthy babies — happier events that provided everyone with some much-needed hope amid the despair.
Figure. Induction of General Anesthesia in the Operating Room of the Deployable Field Hospital (Panel A) and Cleaning and Preparation of an Injured Foot (Panel B).
The nature of the disaster, which left many people injured or killed, resulted in a shift in our mission, from saving lives to treating many previously untreated earthquake injuries. These cases included trauma to the head and extremities, as well as delayed complications of trauma caused by the earthquake — particularly soft-tissue infections, compartment syndromes, and epidural hematomas. In addition, the large-scale destruction of the public health infrastructure in Bam — as a result of the dust, the cold climate and lack of adequate housing, and the contamination of the water and food supplies — caused serious illnesses in many survivors. Children were particularly affected by the earthquake, in terms of both acute injuries and exacerbations of chronic disease (such as pulmonary, hematologic, and neurologic conditions). An increase in the occurrence of ordinary traumas, such as motor vehicle crashes and injuries, was also seen as a secondary result of the earthquake. Maternal care and neonatal care, especially the latter, represented a substantial portion of the activity in the field hospitals, since so many displaced people were living in tents without adequate heat and water. Psychological trauma from the earthquake was common, often compounding underlying illness and injury. Every single person in Bam suffered devastating loss. Many people lost their entire families, and many children were orphaned.
Disasters follow no rules. The spectrum of threats ranges from natural and man-made disasters (including terrorism) to chemical, biologic, and nuclear weapons of mass destruction. All disasters, regardless of their cause, have similar medical and public health consequences. A consistent medical approach to disasters, based on an understanding of their common features and the response expertise they require, is becoming the accepted practice throughout the world. This strategy, called the mass-casualty-incident response, permits teams from various countries to work together to meet disaster-related needs, despite language and cultural barriers.1,2
The mass-casualty-incident response has four critical medical components: search and rescue, triage and initial stabilization, definitive medical care, and evacuation. Today, the risk of complex disasters, particularly the threat of terrorism and weapons of mass destruction, has increased the need for specialty teams to provide these critical elements of disaster response in austere environments throughout the world. The severity and diversity of injuries, in addition to the number of victims, will be a major factor in determining whether a mass-casualty incident overwhelms the local medical and public health infrastructure.
Medical intelligence is an essential part of an international disaster response. Data on endemic and epidemic illnesses are critical, but an understanding of the cultural and social norms is of equal importance in meeting disaster-related needs. The Bam earthquake was unique in the experience of the U.S. team in that the sex of patients was a consideration in the positioning of the tents. Interpreters are critical assets in all international disasters, and often we did not have enough interpreters to cope with all the patients in the tents. Interpreters were assigned specific areas, such as labor and delivery, so that their skills could be used most effectively.
Trained specialists, however well-intentioned, do not by themselves constitute an effective medical team for a response to international disasters. Critical to a successful medical response to a mass-casualty incident such as the Bam earthquake are important nonmedical elements such as communication, safety, sanitation, and security. Designated members of the International Medical Surgical Response Team are trained to provide these important functions for the team and to serve as liaisons with the appropriate authorities on the scene. This capability greatly facilitated the entire response to the earthquake in Bam, from establishing the field hospital to providing patient care.
As health care professionals, we know that the care of patients is a calling that knows no borders. The Iranians we met displayed great courage and dignity in the face of devastating personal loss. We hope that the support they received from the international community will help to begin the process of rebuilding.
Source Information
From the Department of Surgery, Massachusetts General Hospital and Harvard Medical School, and the International Medical Surgical Response Team — all in Boston.
References
Briggs SM, Brinsfield KH, eds. Advanced disaster medical response: manual for providers. Boston: Harvard Medical International, 2003.
Leaning J, Briggs SM, Chen LC, eds. Humanitarian crises: the medical and public health response. Cambridge, Mass.: Harvard University Press, 1999.(Jay J. Schnitzer, M.D., P)