The Dragon Strikes: Lessons from the Wenchuan Earthquake

Abstract

To know the road ahead, ask those coming back. –Chinese Proverb The devastation caused by the earthquake striking Sichuan Province in southwestern China in 2008, interchangeably referred to as the Wenchuan earthquake or the Sichuan earthquake, posed a severe challenge to anesthesiologists and other medical and rescue personnel. They were faced with the nightmarish task of providing relief to thousands of injured victims, many trapped in isolated areas cut off from timely assistance by impassable roads, disabled communication networks, bad weather, and the sheer number of casualties. Because of our longstanding relationship with Chinese anesthesiologists, the Editor-in-Chief of Anesthesia & Analgesia solicited articles from Chinese anesthesiologists personally involved with the immediate rescue or long-term care of victims of the Sichuan earthquake. Collectively, these articles describe important lessons learned by medical personnel, many of whom risked their lives to provide medical care to survivors at the earthquake's epicenter, and draw on the experience of other physicians treating the thousands of injured survivors after the devastation. The articles have been combined into a single narrative in this special article. The original submissions may be viewed in their entirety online as a supplement at www.anesthesia-analgesia.org. THE DRAGON STRIKES Along the broad eastern edge of the Tibetan plateau, the “roof of the world,” lie the Longshan (“Dragon's Gate”) mountains and the Longshan thrust fault that created them. On May 12, 2008, at 14:28 local time, this fault ruptured in several places along its 155-mile length, causing a massive earthquake registering 8.0 on the Richter scale (Figs. 1 and 2). The quake lasted about 2 minutes and struck with a force 30 times greater than the 1995 Great Hanshin earthquake near Kobe, Japan, that killed 5100 people. Within hours, >69,000 people were dead, nearly 400,000 injured, and millions displaced in what experts have called the 11th deadliest earthquake on record (Table 1, No. 1). Moments after the quake, thousands of victims lay trapped in collapsed buildings, and landslides blocked all roads into the mountainous zone of the epicenter (Fig. 3).Figure 1.: Location of the 2008 Sichuan earthquake (from the United States Geological Survey, available at: http://neic.usgs.gov/neis/eq_depot/2008/eq_080512_ryan/neic_ryan_l.html).Figure 2.: Shake map showing the intensity of ground movement along the fault line (from the United States Geological Survey, available at: http://earthquake.usgs.gov/eqcenter/shakemap/global/shake/2008ryan/).Table 1: Internet Sites Referenced in the TextFigure 3.: Devastation from the Sichuan earthquake (available at: http://www.internationalrivers.org/files/images/Sichuanearthquake.preview.jpg).THROUGH THE DRAGON′S GATE As soon as news of the quake arrived at Daping Hospital in Chongqing, 250 miles from the epicenter, a medical rescue team began mobilizing to go to the epicenter at Wenchuan. The experience of this group typifies the frustrations awaiting rescue and relief workers (Supplement 1, see Supplemental Digital Content 1, https://links.lww.com/AA/A64). The Chongqing team, comprising 27 medical personnel, including 3 anesthesiologists, set out for the epicenter about 22 hours after the initial quake. They had no way of knowing the extent of the devastation that awaited them, because most of the communication infrastructure in Sichuan Province had been destroyed. Entire counties in the impact zone could not be reached (Supplement 2, see Supplemental Digital Content 2, https://links.lww.com/AA/A66) (Table 1, No. 2). Seven hours later when they reached Dujiangyan, halfway to the epicenter, they began to appreciate the magnitude of the disaster (Fig. 4).Figure 4.: Collapsed building in Dujiangyan (available at: http://en.wikipedia.org/wiki/File:Collapsed_Building_in_Dujiangyan_-_2008_Sichuan_earthquake.jpg).They discovered that thousands had been killed in Dujiangyan, including hundreds who died in the collapse of a hospital, and some 1000 students who were killed when their school buildings collapsed. Although the scene that greeted these medical relief workers was grim, it represented only a small part of the devastation elsewhere in the region. In addition, the Chongqing medical team discovered that their preparations had been inadequate, including an absence of an emergency generator, water purification equipment, satellite communications equipment, and drugs to protect the team against diseases such as visceral leishmaniasis. The Chongqing medical rescue team also encountered significant obstacles to reaching victims, including aftershocks and unpredictable landslides. They had to take a detour of >600 miles to reach Wenchuan. Along the way, one of the team's minivans was crushed by falling rocks (Fig. 5) after a strong aftershock (Fig. 6). Fortunately, no one was seriously hurt, but thousands of people died in such landslides on roads elsewhere.Figure 5.: Many drivers were injured by rocks displaced by strong aftershocks (available at: http://i.dailymail.co.uk/i/pix/2008/05/16/article-1020063 to 0145B25E00000578 to 564_468x313_popup.jpg).Figure 6.: Aftershocks (orange circles) of the 2008 Sichuan earthquake. Red dots show the depth of underground plate movements (available at: ftp://hazards.cr.usgs.gov/maps/sigeqs/20080512/20080512.jpg).The Chongqing medical rescue team finally reached Wenchuan county seat 96 hours after the initial earthquake. There they found many traumatized and dehydrated victims in danger of wound infections and in need of immediate surgery. Nearly all equipment in local hospitals, including laboratory and imaging equipment, had been destroyed, but some monitors, anesthesia machines, surgical dressings, and instruments were still available. The difficulties experienced by the Chongqing medical rescue team underscore 2 of the most medically significant aspects of this disaster: (1) the delay in reaching and treating the injured, and (2) the need to transport many victims out of the region. With many hospitals destroyed (Fig. 7) and medical personnel killed or injured, those in need of treatment often had to make their way without assistance to the nearest undamaged facilities. Many of these patients flooded into West China Hospital in Chengdu. This facility, about 60 miles from the epicenter, has 4300 beds and is among the largest and most advanced diagnostic and treatment centers in China. The Department of Anesthesiology includes 55 attending physicians and >150 residents. Many of the lessons learned from the quake in Sichuan come to us from the faculty of this department and are presented here. The first lesson, as stated by one author in this group, is that in such a disaster, one must remain safe to help others and not become an additional casualty.Figure 7.: Destroyed hospital. (Reproduced with permission from Nick Kozak, photographer.)CRITICAL LESSONS Review Hospital and Operating Room Seismic Safety and Train Operating Room Physicians in Emergency Medical Procedures Dr. Yunxia Zuo, Vice-Director of the Department of Anesthesiology, was at work in her office at West China Hospital when the building began to shake. She left her office and found a chaotic scene, with surgeons, anesthesiologists, and nurses scrambling toward nearby stairwells. Dr. Zuo urged them to shelter in small rooms such as closets and bathrooms rather than in stairwells, which could have proven unstable and dangerous. Some listened to her but others just went down whatever staircase they could find. Most operating room (OR) personnel stayed with their patients, sometimes after an initial period of taking cover. And most of them, although frightened, continued their clinical work until they could be relocated outside or elsewhere (Yunxia Zuo, MD, PhD, e-mail communications, June 11, 2009). It may have been Dr. Zuo's experience in those first frantic moments immediately after the quake that inspired the study she and her colleagues conducted several weeks later (Supplement 2). They sought to document OR conditions and the behavior of medical personnel throughout Sichuan Province at the time of the disaster. To determine what happened to them and their patients that afternoon and how their facilities held up after the earthquake, researchers and statisticians from the West China Hospital Department of Anesthesiology sent a 64-item questionnaire to department heads in 237 large and medium-sized hospitals in Sichuan. Only anesthesiologists who had been working in ORs at the time of the quake were invited to respond. Data gathered from 220 responses revealed that the reactions of the staff at West China Hospital were fairly typical of what went on in ORs elsewhere in the region. The 220 responses documented that at the time of the earthquake, there were at least 600 surgeons, 350 anesthesiologists, and 420 nurses at work in ORs around the Sichuan province. The actual numbers are higher because not all hospitals responded to the survey. Unfortunately, however, only 36.5% of the hospitals located in the zone of the epicenter could contribute to the survey because some hospitals in the area had been totally destroyed. The loss included an estimated 260 medical personnel killed and 780 injured (Yunxia Zuo, MD, PhD, e-mail communication, June 4, 2009). In the ORs that did not collapse, the most dangerous structural damage was to mechanized doors that could not be opened (25.5%). More than 30% of these ORs lost electricity and almost as many lost their oxygen supply. Most anesthesiologists remained with patients. Nearly all reported feelings of fear and helplessness. Not surprisingly, those who had received some previous emergency fire and earthquake training reported feeling calmer, more confident, and less helpless than those who had not received such training. Review and Evaluate Triage Procedures in Preparation for Large-Scale Disasters When the temblor struck, Dr. Jin Liu, Chair of the Department of Anesthesiology at West China Hospital, rushed to check on the ORs where 55 procedures (including 45 patients under general anesthesia) were then in progress (Supplement 3, see Supplemental Digital Content 3, https://links.lww.com/AA/A67), and because of concern that the department might soon be overwhelmed with injured patients, decisions had to be made as to which operations to continue and which to terminate (Yunxia Zuo, MD, PhD, e-mail communication, June 4, 2009). Before long, a flood of victims began pouring in from the most severely affected areas in the mountains. The casualties came to West China Hospital in waves, arriving first via helicopter and several days later in vehicles after the army began to repair the mountain roads. Eight days after the quake, there was another major influx of patients, the result of triage efforts at an army airport, as well as transfers from nearby hospitals and emergency facilities. In the month after the earthquake, 2695 victims would be treated at West China Hospital and 875 quake-related procedures performed in the hospital's ORs (Supplement 3). The large numbers of casualties streaming into West China Hospital and the severity and type of their injuries forced medical personnel to rethink their approach to triage. According to one group of authors (Supplement 4, see Supplemental Digital Content 4, https://links.lww.com/AA/A68), when there are so few facilities to care for so many casualties, medical care must focus on those who are most likely to survive rather than those who are most critically ill, with emphasis on efficient use of available resources and minimizing waiting time for victims likely to survive. The West China Hospital group conducted triage in a 3-part process: (1) collecting physiological data including assessment of vital signs and level of consciousness; (2) collecting anatomical data and identifying “significant injuries” (e.g., multiple long-bone fractures); and (3) assessing the mechanism of injury. The authors reported that “by the second and third steps . . . we triaged approximately 20% of patients as urgent, having only 34 min elapsed.” The greatest threat to efficiency in evaluating patients often came from the “walking wounded,” victims not in immediate need of critical care and comprising the majority of casualties presenting to West China Hospital. These people (849 patients) were often the first to arrive at the hospital asking for help. They added to the already confused situation by crowding into the hospital's emergency department, interfering with patient evaluation times, and delaying treatment for the critically injured. The authors emphasized that “in a disaster medical triage system, it is not only very important to give treatment to the most critically ill, but also to triage the walking wounded out of the emergency department” (Supplement 4). Be Prepared to Treat Injuries Common to Earthquake Victims Most patients admitted to West China Hospital had fractures. Many had to undergo amputations. Orthopedic, craniocerebral, thoracic, and abdominal injuries were common. At West China Hospital, unlike the situation in the field where regional anesthesia was the rule, most of the 875 surgical procedures were performed using general anesthesia (70.5%) (Supplement 5, see Supplemental Digital Content 5, https://links.lww.com/AA/A69). As more time elapsed, and the time pressure decreased, the use of regional anesthesia (e.g., brachial plexus block, spinal anesthesia, and epidural anesthesia) increased. Many quake victims had injuries and complications directly related to the treatment delay imposed by the widespread and massive destruction of the transportation infrastructure. Dehydration and electrolytic disturbances were common. Crush syndrome, accompanied by gas gangrene and renal failure, was a common complication in patients who had been buried under rubble for a long time before being rescued (Fig. 8). The inordinate number of gas gangrene cases called for special attention. These patients became so numerous that West China Hospital physicians introduced specific testing (serum potassium and wound smear Gram stain/culture) for gas gangrene and crush syndrome into their triage algorithm to identify and assist these victims quickly (see Supplemental Digital Content 4, https://links.lww.com/AA/A68, and Supplemental Digital Content 6, https://links.lww.com/AA/A70).Figure 8.: Man caught under rubble (available at: http://hailin.files.wordpress.com/2008/05/man_under_earthquake.jpg).Hospital physicians soon noticed an unexpected iatrogenic complication caused by well-intentioned butuntrained rescuers. As described by one source, “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” (Fig. 9) (Supplement 6, see Supplemental Digital Content 6, https://links.lww.com/AA/A70). In their zeal to rescue trapped victims, untrained rescuers failed to protect victims from the sudden revascularization of a limb after prolonged ischemia, with devastating results.Figure 9.: Woman rescued after being trapped for 50 hours under debris (available at: http://www.aems.uiuc.edu/images/800px-Sichuan_earthquake_save.jpg).Provide Pain Management In the aftermath of the quake, researchers from West China Hospital sought to determine how effectively the victims' pain had been treated and sent trained interviewers to 7 towns near the epicenter to conduct face-to-face interviews with quake-injured patients (Supplement 7, see Supplemental Digital Content 7, https://links.lww.com/AA/A71). In all, 848 victims were questioned about the treatment of their pain before and after they reached the hospitals and during the postoperative period. The results were disturbing. Although these victims experienced severe pain from their injuries, very few received any pain treatment at all after the quake. The treatment they did receive was often inadequate, even after they had been transferred to the hospital. The researchers described as “astonishing” the degree to which pain was neglected in field emergency areas and characterized the underrecognition and undertreatment in general as “hard to comprehend.” Did rescuers assume that victims would ignore their pain because all their attention would be focused on the injury itself and on the possibility of losing their lives? Were pain medications simply unavailable? The researchers were unable to find a clear explanation, and the causes are probably multifactorial. The undertreatment of pain, however, is a matter of concern and controversy worldwide and is common enough that a specific designation, “oligoanalgesia,” is used to describe it (Table 1, No. 3). It is quite that the magnitude of the disaster and the sheer number of victims in pain simply and of the this study the need for greater that for pain after are in for and of the most aspects of was the and with which thousands of people were to work in the rescue and relief after the earthquake, the Chinese thousands of into the Sichuan province. As soon as to the of the quake zone and into the areas to conduct rescue repair roads, and In to hundreds of Chinese the opened its to medical personnel and rescue experts (Table 1, No. 4). Within a few medical had around Sichuan. These set up field hospitals and care and The first regional team arriving at West China Hospital, as one author presented a significant challenge to the numbers of people from of and with of equipment posed a challenge of effectively under such (Supplement 3). the challenge was and by the time these medical left they had treated some patients and performed They also by clinical and and by people (Supplement see Supplemental Digital Content Dr. from the at the of a in critical care and out at West China Hospital for several weeks after the quake. the Chinese to the disaster as very and and that having the to work with Chinese physicians in the emergency department was MD, communication, June Dr. who up the group, called their experience of us for the of our (Table 1, No. of The medical to a major earthquake timely and and of drugs and care in rescue and relief efforts be trained in emergency care and be by of other emergency personnel. must be to that medical personnel work in a safe so that they provide care for the casualties rather than casualties In to the lessons in this many more could be for personnel with victims on rather than in hospital. These would for in regional anesthesia and for providing assistance in resources are or The of victims of crush injuries found after hours or days with limbs must also be resources the earthquake and aspects of the are in on the THE THE DRAGON The damage caused by this earthquake was so and widespread that the road to for Sichuan Province be long and infrastructure damage has been estimated at of No. 6). and for this work has been Although millions of people are still in the Red that because of of most be into by the of this (Table 1, No. The medical has the work of West China Hospital is the lessons learned during the quake into for earthquake have been and training are for staff anesthesiologists and those from the earthquake's epicenter zone (Yunxia Zuo, MD, PhD, e-mail communication, June 4, 2009). The hospital has a it with hospitals in the region. This has already and treatment for patients (Table 1, No. 8). Most West China Hospital and staff have that the emphasis during the of their medical relief work must be on and This no an that although and hospitals be building and displaced many left by the quake are not as as collapsed As of this several including the Red have the death at greater than estimated (Table 1, No. Although numbers are not available and are there is that many hundreds of these casualties were (Table 1, No. The death of so many throughout the have significant that be to and to The of such a disaster and their long-term although to than damage to the are a The of Anesthesia & Analgesia the of our colleagues in China. to provide multiple of their after the Sichuan earthquake has our their to this article. the greater is the their patients. to patient and their and in the most of make us to be the of Anesthesiology, West China Hospital, Sichuan of Anesthesiology of Daping Hospital, of Medical of Anesthesiology, Hospital of Sichuan Medical of Anesthesiology and Pain The of Medical at Chinese West China Hospital, Sichuan of Emergency West China Hospital, Sichuan of Pain and Operating United Hospital, of Emergency Hospital, Hospital, and of Department of Anesthesiology, of in by a from the Chinese Medical from the of and general from the Medical of Sichuan the Department of Anesthesiology of the West China Hospital of Sichuan and the of of Sichuan