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:
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