Tsunami in Thailand — Disaster Management in a District Hospital
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《新英格兰医药杂志》
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On the morning of December 26, 2004, a magnitude 9.0 earthquake occurred off the west coast of Sumatra. The tsunami that followed swept across the Indian Ocean, devastating areas of Indonesia, affecting the Indian Ocean islands, Thailand, Sri Lanka, India, Bangladesh, Myanmar, Malaysia, and parts of Africa, and resulting in more casualties than any other tsunami in recorded history. All told, as of mid-February, an estimated 214,000 people had been killed, at least 142,000 were missing, and more than 34,000 were injured.1
In Thailand, 5395 people are confirmed dead, 2998 are missing, and 8457 have been injured.2 The most severely affected provinces were Phangnga, Krabi, Phuket, and Ranong, with the greatest damage in Phangnga, on the southwest coast.2 Before the tsunami, this primarily agricultural area had a population of 234,188.3 Tourism is an important source of its revenue: the province had nearly 100 hotels, many of them on or near the beach in the now-shattered resort area of Khao Lak (see photographs and map). December being peak tourist season, the resorts were full. Khao Lak is a tropical paradise with beautiful cliffs, hills, beaches, estuaries, and mangroves, but the tsunami devastated it, turning most buildings to rubble. The fishing village of Ban Nam Khem was hit particularly hard; many of its people died, and all its houses and most of its fishing fleet were destroyed.
Satellite Views of Blue Village Pakarang Resort, Khao Lak, Thailand, before (Panel A) and after (Panel B) the Tsunami.
The inset map shows the affected coastline of southern Thailand.
National University of Singapore/CRISP/IKONOS.
One of the principal referral centers for people injured in the tsunami was Takuapa Hospital, a general hospital in Phangnga with 177 beds, a 6-bed intensive care unit, 4 operating rooms, an emergency department, and medical, surgical, and pediatric wards. The staff includes 118 nurses, 5 junior doctors, 1 general surgeon, 2 orthopedic surgeons, 2 general physicians, 3 pediatricians, and 1 ophthalmologist. The hospital has four ambulances and on-site radiology, biochemistry, and microbiology laboratories. The emergency department consists of one large, open room, normally staffed by one physician, two nurses, and one assistant.
At around 10:30 a.m. on December 26, an unidentified caller informed the hospital that a large wave had swept across Ban Nam Khem, leaving many casualties. An ambulance dispatched to investigate found a large area of flooding, along with many injured or dead people. The main coastal road is a variable distance from the sea, and some areas had been spared. People who had been on higher ground when the tsunami hit were instrumental in bringing injured persons to the hospital.
As events rapidly unfolded, the staff implemented the hospital's Major Incident Policy — a protocol that had been practiced two weeks earlier, when a disaster was simulated involving 80 people injured in a traffic accident. Nurses were called in from their on-site residence by loudspeaker. All hospital doctors were telephoned, and a team of nine doctors — the hospital director, a general surgeon, an orthopedic surgeon, a pediatrician, two general physicians, an ophthalmologist, and two junior doctors — was assembled.
Three of the hospital's doctors were caught in the tsunami; one general physician died, and two affected physicians survived and joined the hospital team on the second day. Two other staff members (one nurse and one library assistant) died during the tsunami, and one ambulance was lost.
Triage was carried out by senior nurses as follows: Code Blue covered persons who were already dead or who had very severe injuries unlikely to be compatible with survival; the dead were initially transferred to the outpatient department, and the severely injured were kept in the emergency room. Code Red covered persons with severe injuries who were deemed likely to survive if they received treatment; these patients were seen, assessed, treated by a doctor as soon as possible, and admitted to a ward or the intensive care unit. Code Yellow referred to patients with injuries such as nonbleeding lacerations, noncritical head injuries, and crush or blunt trauma not associated with shock, who were judged able to wait to be seen; these patients were assessed and treated by a doctor as one became available and were admitted as appropriate. Code Green covered patients with minor injuries, who were assessed and treated by nurses in the outpatient area and were discharged as appropriate. Signs defining these codes were posted on the emergency room wall. After 105 bodies had arrived, the dead began to be taken directly to one of two nearby temples for temporary storage and forensic identification. Temporary shelters were erected on the hospital grounds for patients' relatives.
The injuries were of two main types: aspiration and trauma. Aspiration was assessed according to the clinical history, the degree of dyspnea, and oxygen saturation on pulse oximetry. Patients with suspected aspiration underwent chest radiography and were admitted if they had a need for supplemental oxygen, an oxygen-saturation value of less than 90 percent, or an abnormal chest radiograph. The most severely affected patients were intubated and ventilated and either transferred to the intensive care unit or, once this unit had reached twice its normal capacity, to another area hospital. Patients with suspected mild aspiration were discharged and given oral amoxicillin for five days; those who were admitted were given parenteral cefotaxime or ceftriaxone, plus gentamicin.
Trauma was categorized as abrasions, superficial or deep lacerations, open or closed fractures, head injuries, or other. Superficial wounds were cleaned, and the patients were discharged with cloxacillin or ofloxacin. Patients with deep wounds were admitted for wound cleaning and débridement. Fractures were treated on day 2, when casts were applied to closed fractures and open fractures were débrided and stabilized. Patients with open fractures were treated with intravenous cloxacillin or cefazolin, with or without gentamicin. Oral acetaminophen, ibuprofen, or both were used for pain relief for minor injuries, and morphine or meperidine was used for severe injuries.
A total of 986 patients were seen in the emergency department on December 26, and 628 were admitted (see graph). During the first week, 2285 patients with trauma were seen — 251 with major trauma, 389 with intermediate-level trauma, and 1645 with minor trauma. The least severely injured received care in any suitable hospital space, including the conference room. By the evening of the first day, physicians from other hospitals had arrived with dressings and drugs. On December 27, all patients were reexamined and sent to the operating room as necessary for further débridement, limb amputation, or other surgery. The four operating rooms were in use around the clock; 683 operations were performed in the first week. Many wounds rapidly became foul-smelling and were associated with frank pus, and metronidazole was added routinely to antimicrobial treatment in wounded patients.
Number of Inpatients Each Day at Takuapa General Hospital, December 25, 2004, through January 1, 2005.
Teams of doctors, including critical care physicians, pulmonologists, surgeons, and anesthesiologists, continued to arrive from other hospitals. By December 28, most of the non-Thai patients and about half of the Thai patients had been transferred to hospitals in Bangkok and elsewhere. By January 3, 2005, most health care volunteers had left.
By two weeks after the disaster, most tsunami-affected patients had been transferred or discharged. The hospital had returned to normal activities, although reams of photographs and details about missing persons remained pinned to bulletin boards at the hospital entrance. Only five inpatients died during the first week, although some of the severely injured who were transferred to other centers no doubt died en route or at their destinations. The experiences at Takuapa Hospital during this tragic week demonstrate the importance of having a well-thought-out and rehearsed disaster plan, even in a small district hospital; members of the hospital staff were prepared, though none could have predicted the enormity of the crisis that would require the plan to be put into action.(Charnkij Wattanawaitunech)
On the morning of December 26, 2004, a magnitude 9.0 earthquake occurred off the west coast of Sumatra. The tsunami that followed swept across the Indian Ocean, devastating areas of Indonesia, affecting the Indian Ocean islands, Thailand, Sri Lanka, India, Bangladesh, Myanmar, Malaysia, and parts of Africa, and resulting in more casualties than any other tsunami in recorded history. All told, as of mid-February, an estimated 214,000 people had been killed, at least 142,000 were missing, and more than 34,000 were injured.1
In Thailand, 5395 people are confirmed dead, 2998 are missing, and 8457 have been injured.2 The most severely affected provinces were Phangnga, Krabi, Phuket, and Ranong, with the greatest damage in Phangnga, on the southwest coast.2 Before the tsunami, this primarily agricultural area had a population of 234,188.3 Tourism is an important source of its revenue: the province had nearly 100 hotels, many of them on or near the beach in the now-shattered resort area of Khao Lak (see photographs and map). December being peak tourist season, the resorts were full. Khao Lak is a tropical paradise with beautiful cliffs, hills, beaches, estuaries, and mangroves, but the tsunami devastated it, turning most buildings to rubble. The fishing village of Ban Nam Khem was hit particularly hard; many of its people died, and all its houses and most of its fishing fleet were destroyed.
Satellite Views of Blue Village Pakarang Resort, Khao Lak, Thailand, before (Panel A) and after (Panel B) the Tsunami.
The inset map shows the affected coastline of southern Thailand.
National University of Singapore/CRISP/IKONOS.
One of the principal referral centers for people injured in the tsunami was Takuapa Hospital, a general hospital in Phangnga with 177 beds, a 6-bed intensive care unit, 4 operating rooms, an emergency department, and medical, surgical, and pediatric wards. The staff includes 118 nurses, 5 junior doctors, 1 general surgeon, 2 orthopedic surgeons, 2 general physicians, 3 pediatricians, and 1 ophthalmologist. The hospital has four ambulances and on-site radiology, biochemistry, and microbiology laboratories. The emergency department consists of one large, open room, normally staffed by one physician, two nurses, and one assistant.
At around 10:30 a.m. on December 26, an unidentified caller informed the hospital that a large wave had swept across Ban Nam Khem, leaving many casualties. An ambulance dispatched to investigate found a large area of flooding, along with many injured or dead people. The main coastal road is a variable distance from the sea, and some areas had been spared. People who had been on higher ground when the tsunami hit were instrumental in bringing injured persons to the hospital.
As events rapidly unfolded, the staff implemented the hospital's Major Incident Policy — a protocol that had been practiced two weeks earlier, when a disaster was simulated involving 80 people injured in a traffic accident. Nurses were called in from their on-site residence by loudspeaker. All hospital doctors were telephoned, and a team of nine doctors — the hospital director, a general surgeon, an orthopedic surgeon, a pediatrician, two general physicians, an ophthalmologist, and two junior doctors — was assembled.
Three of the hospital's doctors were caught in the tsunami; one general physician died, and two affected physicians survived and joined the hospital team on the second day. Two other staff members (one nurse and one library assistant) died during the tsunami, and one ambulance was lost.
Triage was carried out by senior nurses as follows: Code Blue covered persons who were already dead or who had very severe injuries unlikely to be compatible with survival; the dead were initially transferred to the outpatient department, and the severely injured were kept in the emergency room. Code Red covered persons with severe injuries who were deemed likely to survive if they received treatment; these patients were seen, assessed, treated by a doctor as soon as possible, and admitted to a ward or the intensive care unit. Code Yellow referred to patients with injuries such as nonbleeding lacerations, noncritical head injuries, and crush or blunt trauma not associated with shock, who were judged able to wait to be seen; these patients were assessed and treated by a doctor as one became available and were admitted as appropriate. Code Green covered patients with minor injuries, who were assessed and treated by nurses in the outpatient area and were discharged as appropriate. Signs defining these codes were posted on the emergency room wall. After 105 bodies had arrived, the dead began to be taken directly to one of two nearby temples for temporary storage and forensic identification. Temporary shelters were erected on the hospital grounds for patients' relatives.
The injuries were of two main types: aspiration and trauma. Aspiration was assessed according to the clinical history, the degree of dyspnea, and oxygen saturation on pulse oximetry. Patients with suspected aspiration underwent chest radiography and were admitted if they had a need for supplemental oxygen, an oxygen-saturation value of less than 90 percent, or an abnormal chest radiograph. The most severely affected patients were intubated and ventilated and either transferred to the intensive care unit or, once this unit had reached twice its normal capacity, to another area hospital. Patients with suspected mild aspiration were discharged and given oral amoxicillin for five days; those who were admitted were given parenteral cefotaxime or ceftriaxone, plus gentamicin.
Trauma was categorized as abrasions, superficial or deep lacerations, open or closed fractures, head injuries, or other. Superficial wounds were cleaned, and the patients were discharged with cloxacillin or ofloxacin. Patients with deep wounds were admitted for wound cleaning and débridement. Fractures were treated on day 2, when casts were applied to closed fractures and open fractures were débrided and stabilized. Patients with open fractures were treated with intravenous cloxacillin or cefazolin, with or without gentamicin. Oral acetaminophen, ibuprofen, or both were used for pain relief for minor injuries, and morphine or meperidine was used for severe injuries.
A total of 986 patients were seen in the emergency department on December 26, and 628 were admitted (see graph). During the first week, 2285 patients with trauma were seen — 251 with major trauma, 389 with intermediate-level trauma, and 1645 with minor trauma. The least severely injured received care in any suitable hospital space, including the conference room. By the evening of the first day, physicians from other hospitals had arrived with dressings and drugs. On December 27, all patients were reexamined and sent to the operating room as necessary for further débridement, limb amputation, or other surgery. The four operating rooms were in use around the clock; 683 operations were performed in the first week. Many wounds rapidly became foul-smelling and were associated with frank pus, and metronidazole was added routinely to antimicrobial treatment in wounded patients.
Number of Inpatients Each Day at Takuapa General Hospital, December 25, 2004, through January 1, 2005.
Teams of doctors, including critical care physicians, pulmonologists, surgeons, and anesthesiologists, continued to arrive from other hospitals. By December 28, most of the non-Thai patients and about half of the Thai patients had been transferred to hospitals in Bangkok and elsewhere. By January 3, 2005, most health care volunteers had left.
By two weeks after the disaster, most tsunami-affected patients had been transferred or discharged. The hospital had returned to normal activities, although reams of photographs and details about missing persons remained pinned to bulletin boards at the hospital entrance. Only five inpatients died during the first week, although some of the severely injured who were transferred to other centers no doubt died en route or at their destinations. The experiences at Takuapa Hospital during this tragic week demonstrate the importance of having a well-thought-out and rehearsed disaster plan, even in a small district hospital; members of the hospital staff were prepared, though none could have predicted the enormity of the crisis that would require the plan to be put into action.(Charnkij Wattanawaitunech)