Armenia after the earthquake (1988)

In 1988 I was in Armenia after the earthquake with a team from The International Resuscitation Research Institute of the University of Pittsburgh led by Dr. Peter Safar. I wrote a paper after this experience which reflected a lot of the lessons learned. I don’t think I ever actually published it.

It was our observation that victims of this disaster fell into four discrete classifications:

1) Those killed outright, or expected to die within a few minutes from irreversible injury processes,

2) Those sustaining serious trauma, trapped in rubble, and who would require difficult, time consuming manipulations to be extracted, followed by advanced life support maintenance until they could be transferred to a tertiary care facility for surgery and intensive care.

3) Those potentially survivable if rendered immediate first aid of a simple nature, such as stopping bleeding, stabilization of fractures, maintenance of airway until further care can be accessed.

4) Those with minimal injuries trapped in “cells” where they would have some protection from further trauma until ultimately rescued at some time in the future.

Victims in class 1 were obviously unsalvageable as pointed out in current ATLS protocols. Victims in class 2 who were severely injured to the point where sophisticated life support was urgently necessary ultimately proved non-salvageable since there was no immediate followup technology available to support their hemodynamics. This would be particularly true for victims requiring CPR. The time spent on this classification of victims in the early stages would not justify taking time away from others who might sustain more benefit and expending fewer resources. Even if ultimately extricated, they would not likely survive transport in a mandatory “scoop and run” milieu, and would tie up critical care systems in secondary and tertiary areas, with only marginal probability of survival.

Victims in class 3 stood to reap the most benefit using the least formal technology. This means that the most benefit for the greatest number might be accomplished using a system of brief but effective first aid, given by uninjured bystanders to stabilize those most likely to survive extraction and subsequent transfer after triage. Victims who could be stabilized by initial LSFA might be accessed by “secondary sweep” teams sometime later and transferred out to secondary centers for titrated care. LSFA is expected to save lives primarily when started within seconds or minutes of impact. Advanced Trauma Life Support is expected to save lives primarily when advanced airway control, IV fluid loading, and oxygen inhalation are begun during extrication. This requires an effective, preexisting organizational structure that can provide immediate alert that a disaster has occurred, and can communicate this information through secure communication links. This must result in rapid deployment of the most appropriately trained personnel with the necessary supplies and equipment to the disaster scene.

Following the initial stabilization efforts by uninjured bystanders, and the secondary “sweep” of the area by the search/rescue teams, attention must then be turned to those in class 4 who are trapped in “cells” of rubble and debris. Such victims are placed in a position of “natural selection”. By the nature of their situation, they would either survive until extrication or they wouldn’t, their fate dependent on engineering rather than medical technology. If they survive the initial hours after the event, they have not only the potential to wait until advanced rubble clearing technology can be transported to the scene, but actually may be protected from further injury during subsequent aftershocks. If their position could be determined, by dogs or advanced search technology, they could survive until rubble could be removed under the guidance of structural engineers. Speed is still of the essence since the rubble could shift at any moment.

“Disaster reanimatology”, in the ideal setting, begins with immediate LSFA by uninjured co-victims, before, during, and after extrication of easily accessible, critically injured victims. For this to be effective would require a significant percentage of the population to learn the six basic steps of LSFA: 1) airway control using the head-tilt and/or jaw-thrust and/or manual clearing of the mouth and throat; 2) exhaled air ventilation (mouth-to-mouth or mouth-to-nose) ; 3) external hemorrhage control by compression; 4) positioning for coma; 5) positioning for shock; and 6) rescue pull without adding injury. Some ATLS measures such as administration of oxygen and intravenous fluids can be begun when the injured victim’s face or an arm is free. ATLS should be augmented by secondary triage and rapid transport with life support of potentially salvageable victims to the most appropriate hospitals for definitive surgical care and PLS. The closest functioning hospitals in an earthquake may be far from the disaster area. A key factor in earthquakes is accessibility of victims, i.e., search and rescue. Engineers should design airliftable extrication devices that do not injure those buried (rescue engineering).

Beginning at the site of the event, victims who are judged to be salvageable should be stabilized rapidly using quick, efficient first aid designed to stop the progression of the effects of traumatic injury long enough to transport the patient to a secondary site. Upon reaching the secondary site, in a safer position, out of the way of rescue technology, victims can be given more substantial stabilization pending their transfer out to more sophisticated centers, where more diverse procedures may be available. As transported patients proceed away from the center of the event, more and more are discharged after appropriate treatment. As the progression continues, only the most seriously injured patients actually reach the tertiary care facilities in major cities. The level of specialization and technological innovation should increase as one travels outward from the center of the disaster scene. Part of the protocol for choosing patients most likely to benefit from transfer to the nearest secondary center would be the likelihood of surviving the transport after basic first aid stabilization. The point is getting as many potential survivors as possible out of the area to another place where they can be triaged and then treated. Stacking victims would not be out of the question. Accordingly, triage should be designed such that simplest modalities should be available at the center of the disaster, and treatment/stabilization should become more diverse as victims are shipped outward from the scene. The hallmark of efficiency and effectiveness in such circumstances is simplicity and mobility.

It seems clear that advanced technology has little place in the initial few hours after a major disaster. While ATLS can be administered by paramedics under physician guidance via radio, resuscitation surgery requires medical-surgical reanimatology teams including an anesthesiologist or nurse anesthetist and a general surgeon with experience in traumatology. Such surgical reanimatology teams would have to be assembled quickly and transported to the disaster zone as rapidly as possible. Local/regional specialists could be mobilized most rapidly, if they are available. They may need to be equipped with mobile operating room gear and supplies, and ideally they should be airlifted by helicopter. Alternatively, they can utilize functional hospital facilities close to the disaster zone. Probably this technology can do little if they arrive later than 6-12 hours after injury. In the past, aid across borders has come late, with no impact on immediate life sustaining. Although well meant, this aid is often in the form of specialized skills, equipment and supplies that are not needed then. There is little reason to have “specialists” directly in the disaster zone. High technology at the scene is difficult to mobilize and apply under confused and difficult circumstances. Specialists should provide services at areas equipped with the necessary technology to maximize their usefulness for patients previously triaged.

Transportation was a critical element for the evacuation of the injured to intact treatment facilities. Approximately 154 km. of roads were disrupted by the quake. Remarkably, they were repaired to operable conditions within 2 days. The key issue is making “transportation” work. Again, a minimum of technology would be available, so the idea of “scoop and run” would certainly apply here. Due to mass confusion and traffic problems ground “transportation medicine” technology would be exceedingly difficult, if not impossible, to mobilize in enough numbers to be meaningful. Victims requiring sophisticated critical care support systems would have to have a survivability index high enough to be supportable by conservative airway protection, IV fluid repletion, direct pressure applied to bleeding sites, and stabilization of fractures until the arrival of mobile critical care support teams, who could extricate, treat, triage and transport.

Martial law should be imposed immediately by an armed, authoritarian faction, presumably the military, which is highly mobile and authoritative. Particularly, traffic control must be immediately established by these same factions to facilitate transfer of patients to secondary centers. This was not done soon enough in Leninikan, and roads quickly clogged with relatives trying to get to the scene, severely obstructing medical transfers.

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