Injury (1990) 21, 25-28
Printed in Great Britain
Acute haemodialysis earthquake disaster
25
during the Armenian
J. E. Tattersall’
N. T. Richards’
M. McCann’
Research Registrar
Honora y Senior Registrar
Sister
T. Mathias ’
A. Samson2
A. Johnson’
Sister
Sister
Chief Technician
‘Renal Unit, St Bartholomew’s Hospital, London, UK 2Renal Unit, St Thomas’s Hospital, London, UK
On the 7 December 7988 an earthquake sfruck a densely populated region in northern Armenia. Up to 50 000 people “were hilled and many thousands were seriously injured. At least 385 of these casualties developed acute renal failure seconday to crush syndrome and required dialysis. 7k Armenian renal unit at Yerevan, in common with units elsewhere, was already oversfretckd to cope with fk dialysis requirements of their patients with chronic renal failure before fk earfhquake. Most of tk patients requiring dialysis were transferred to other hospitals in tk USSR but 120 patients remained in Y&van. tk majority at tk regional renal unit, overwklming tk resources. We assisted by taking a team of dialysis personnel, equipped with portable haemodialysis machines, to Yerevan. We performed 57 haemodialysis sessions and treated 15 patitwfs, 13 of whom ultimately survived.Valuable lessons were learnt about tk medical management of disasters abroad.
Introduction On the 7 December 1988, at 11:20 local time, a severe earthquake struck a densely populated region in north Armenia. Three major towns and several villages were affected. The worst damage was in the town of Spitak which was almost completely destroyed. The Armenian second city and main cultural centre, Leninakhan, was 80 per cent destroyed. The earthquake struck at a time when most people were indoors. The initial shock was followed after 4 min by an aftershock which caused buildings left standing to collapse onto people who were in lower floors or in the street immediately outside the buildings, attempting to escape. Up to 50000 people died and some thousands of survivors were seriosuly injured by crushing. Crushed muscles release myoglobin which is eventually concentrated in the renal tubules. The patient also loses large volumes of fluid into crushed muscles. This combination of volume depletion and myoglobinuria causes acute renal failure (Bywaters and Beall, 1941) and is preventable by early volume replacement and/or amputation of crushed limbs (Michaelson et al., 1984a, b). In the confusion following the earthquake, many of the crushed survivors did not 0 1990 Butter-worth & Co (Publishers) Ltd 0020-1383/90/010025~4
receive this optimal treatment and developed acute renal failure. This type of renal failure is self-limiting and, if dialysis is required, it is usually only for a period of 2 weeks or less. Complete recovery of normal renal function is usual. The USSR does not report statistics relating to the treatment of renal failure in their country, but it is likely that their situation is similar to the Warsaw pact countries of Eastern Europe which are known to dialyse only about 40 per cent of those patients who require it (European Dialysis and Transplant Association Registry, 1988) due to a severe shortage of equipment and the hard currency required to import disposables. The Republic of Armenia had one dialysis unit serving a population of about three million. This unit had eight haemodialysis machines which were fully occupied in the treatment of 70 patients who had chronic renal failure before the disaster. As a result of the earthquake, at least 385 injured survivors developed renal failure and completely overwhelmed local dialysis facilities. The majority of these patients were transferred to other parts of the USSR for treatment but 120 remained in Yerevan, the Armenian capital.
The British response By the 4th day after the disaster, it became apparent that thousands of survivors had developed acute renal failure. Many of these would require dialysis and the Soviet authorities appealed for outside help, including dialysis equipment and personnel. At this time, the only British team in existence capable of providing a mobile dialysis team was a Royal Air Force unit but this was unacceptable to the USSR. By the 5th day of the disaster, a number of British renal units had donated 23 portable haemodialysis machines and some of these units had personnel standing by. A charity, Aid Armenia, arranged collection and transportation of the machines and bought disposable items sufficient for 1000 dialysis sessions. Nineteen of the machines and other medical supplies left Heathrow airport for Armenia that
26
Injury: the British Journal of Accident Surgery (1990) Vol. 21/No.1
same evening. A mobile dialysis team was organized in less than 24 h by St Thomas’s Hospital, in association with Aid Armenia. This team was equipped with four dialysis machines, disposables for 100 dialysis sessions, drugs, access catheters, one doctor, two nurses and one dialysis engineer. Following a request from the Soviet Embassy in London on the evening of the 5th day, a doctor and a nurse from St Bartholomew’s Hospital Renal Unit also prepared for departure. The two teams met at Heathrow airport the following morning. At this stage we believed that we would be treating patients in Moscow. The combined team and equipment departed from London on the 6th day after the disaster and arrived in Yerevan via Moscow on the following day. All transportation, visas and accommodation had been provided, free of charge, by the Soviet authorities. A further 2 days were spent locating and installing equipment before the first patients were treated on the 9th day after the disaster. We were given space in an X-ray suite in the All Union Surgical Scientific Centre (Fiere I). This hospital contained the only existing renal unit in Armenia and had been designated as the referral centre for crush syndrome and renal failure resulting from the disaster. We performed 57 dialysis sessions on 15 patients over a o-day period. The haemodialysis system we selected was the ‘Sorb/Redy’ type which is portable and simple to operate. In Britain, they are used by haemodialysis patients for holiday dialysis, often in hotel rooms. The system uses 5 litres of dialysate which circulates in a closed loop between the dialyser and a special cartridge which removes wastes (Wing et al., 1983). This avoids the need for a purified water supply required by other types and proved particularly suitable.
Other dialysis teams Of the 120 patients with acute renal failure remaining in Yerevan, 40 were treated ‘conservatively’ and 24 were treated by the Soviet army at a military hospital. This left 56 patients to be dialysed in the Yerevan renal unit. Armenian staff, supplemented by personnel from elsewhere in the USSR, treated 21 of these patients (in addition to their 70 long-term patients) using existing equipment. A team from West Germany arrived in the renal unit on the 4th day after the disaster and treated 20 patients. They had chartered a 747 aircraft and brought with them 12 modem single-pass dialysis machines, two water treatment
Figure 1. British ‘renal unit’ in Yerevan.
plants and 4 tonnes of blood lines and other disposable items. The equipment remained in Yerevan after the German team had left and was installed in place of the original dialysis equipment. Belgian and Dutch teams, in association with the intemational medical organization ‘Medecins Sans Frontiers’, also dialysed small numbers of patients with acute renal failure arising in other Yerevan hospitals. This group continues its work in Yerevan and has set up a new dialysis unit.
The patientsand their treatment We treated 15 patients (ages o-65 years), all of whom had acute renal failure due to crush syndrome and had been evacuated within the first 24 h of the disaster. AU had severe limb trauma, two had fasciotomies and four had above-knee amputations (one bilateral). There were also two spontaneous abortions, one ruptured bladder, one ruptured bowel and two spinal injuries with paraplegia. Many of the wounds were infected. Patients tended to be volume depleted and there was often a large loss of serum from wounds. The patients had received inadequate volume replacement due to a shortage of human plasma, infusion sets and cannulae. Most of the patients were on donated ceftazidime in doses inappropriately high for patients with renal failure and three of these had rashes which settled on stopping the drug. Other adverse features included delayed surgical treatment to wounds and infrequent dressing changes due partly to a shortage of strong analegesics. We treated all patients with daily haemodialysis. This gave us the opportunity to supervise fluid balance. Initial vascular access employed Scribner shunts inserted by the Soviet surgeons, but many of these clotted and the supply of shunts ran out. Therefore, we tended to use double-lumen central venous lines we inserted ourselved under local anaesthetic. We treated infections with vancomycin and gentamycin which are given infrequently in renal failure and we could give all doses ourselves at the time of dialysis. Pethidine was given to any patient in pain. Four of our patients required blood transfusions. Eight patients treated by other teams had had severe transfusion reactions, two of which were fatal. We therefore transfused only after performing bedside cross-matching. Of the 15 patients we treated, eight had recovered their renal function by the time we left, one had died and six were still oliguric. Ultimately, IS of the 15 patients we treated recovered with normal renal function and two died.
Figure 2. Bed-side haemodialysis of an infected patient in the surgical ward.
Tattersall et al.: Acute haemodialysis during the Armenian earthquake
After 5 days working in the relatively protected area we had set up as our ‘renal unit’, we were asked to dialyse three infected patients at the bedside on a surgical ward (Figure 2). The suffering, despair and smell of infected tissue we encountered here was difficult to cope with. Local staff were demoralized by overwork, sleep deprivation and shortages of analgesics and items for basic medical care. During the 4 days we worked on this ward, we provided analgesia, changed dressings and spent a considerable amount of time talking to relatives, patients and staff. We also provided advice and training in the use of dialysis equipment and access. We found the Soviet medical and nursing staff were very keen to learn about our techniques and we took part in ward rounds. Language was not a problem as many of the staff spoke English and there was a supply of willing translators.
Lessons learned The presence of foreign medical teams in a disaster area is not necessarily a great advantage. In our case, we contributed towards saving the lives of 13 young people who might otherwise have died. This amounts to a symbolic gesture in the context of the disaster, although our presence may have resulted in other, less easily measurable benefits. Against this must be set the expense (at least f 160,000) and the use of resources in the disaster area. It is therefore necessary that future medical missions of this type only attend if there is a clear need and that the team is properly equipped and trained to maximal efficiency. The inevitable confusion following a major disaster was increased by inappropriate assistance from abroad. This was due to a serious lack of information. We had no advance knowledge of the kind of work we would be doing or even where we were going and, as a result, some of our equipment was inappropriate. There was also a lack of information on the foreign medical teams. The Soviet authorities often had no idea of what kind of assistance they were getting until after the team had actually arrived. This made coordination and effective deployment of the teams virtually impossible. Many of the problems stemmed from the fact that most of the foreign medical teams were not in existence before this disaster and so lacked experience and organization and their capabilities and composition were unknown. If we are to be of any use in future disasters abroad, we must have our teams prepared, equipped and organized before the disaster. An appropirate response must be planned by personnel who can get to the disaster rapidly and have information on the potential aid teams as well as the conditions at the disaster site. Official requests for assistance had stressed the need for ‘high-tech equipment but we found that there was a more pressing need for basic items such as syringes, needles, etc. As a result, we were well stocked with dialysis equipment but lack analgesics, plasma and buckets (needed for filling our dialysis machines with water). In the event we were able to obtain items we needed from other foreign medical teams but we were clearly wrong to rely on the availability of any equipment in the disaster area. Many of the haemodialysis machines donated by British hospitals were not in working order or lacked essential attachments such as blood pumps. There was no time to check equipment before leaving. Also, much of the equipment was lost due to the enormous volume of (largely inappropriate) donated equipment accumulating in Yerevan. Some of our equipment and personal baggage was removed
27
from our aircraft to make way for a donated CT scanner which was deemed more important! Fortunately, the St Thomas’s team had transported a core of essential equipment and machines, known to be in working order, as baggage’ which came with us on the same aircraft. It was helpful to have packed equipment in such a way that each pack contained a mixture of all items needed, so that even if packs were lost, all essential items would still be present in the remaining packs. At the time of a disaster, personnel are under stress and this is not the right time for a mobile medical team to select and pack equipment. It is essential for us to be ready for future disasters by having comprehensive packs of equipment prepared in advance and stockpiled, ready for immediate use. This will save time and reduce error when they are needed. We found that an important aspect of our work was in simple procedures such as putting up drips, providing analgesia and comforting patients. We felt that our presence improved morale and that it was helpful for the local medical staff, who were suffering from exhaustion and psychological shock, to be supported by people who were not so closely connected with the disaster. In this situation, it is tempting to assume a superiority over the host medical teams. This causes resentment and can negate any beneficial effect of the team’s presence. A disaster is not the best time to introduce new techniques, particularly if done in a patronizing manner. The ‘visiting’ team must work under their host’s supervision as helpers rather than saviours. This should be recognized in the preparation and training of future disaster teams. There are long-term implications of the medical aid to Armenia. Before the earthquake, Armenian medical staff had been isolated from the rest of the medical world. Now, they are using modem medical equipment, including disposables, for the first time. Donated haemodialysis machines remaining in Yerevan after the foreign teams departed have replaced original equipment. These machines are of a type totally unfamiliar to Armenian staff and represent an overnight advance in medical technology equivalent to 20 years’ development. The new machines allow greater numbers of patients with chronic renal failure, not resulting from the disaster to be treated. This has created a sudden and long-term requirements for increased numbers of skilled staff. The maintenance and supply of disposables for this equipment (which must be imported from the West) will cause problems in future when the donated stocks run out.
Conclusions Experience of the Vietnam war has led to a strategy for coping with large numbers of casualties (Eisman, 1967). This requires rapid resuscitation and first aid, usually performed in the field by non-medical personnel, followed by evacuation to a functioning hospital outside the immediate combat area (Rozin and Klauser, 1988). Evacuation and definitive treatment can be delayed up to 24 h but the initial resuscitation can not. This principle was refined and used successfully during the Falkland Islands war where the combat troops themselves carried out the resuscitation (Williams et al., 1982). Analysis of past disasters reveals that the combined effects of the destruction and overload of communication systems precludes outside teams appreciating the scale of the disaster, let alone arriving in time to be of any use. In practice, the first response is given by workers already on the spot or in the immediate vicinity at the time of the disaster (Scanlon, 1988). Furthermore, the
Injury: the British Journal of Accident Surgery (1990) Vol. Zl/No.I
28
influx of foreign teams inappropriately equipped and too late to be of any use will waste resources and increase confusion. Our role in assistance in this first response may be more effective if it is limited to perfecting our own local disaster management plans, which can then be used as an example for other countries. However, it may be practical for foreign teams to provide specialized assistance at a later stage to treat delayed complications such as renal failure. Outside medical teams may also help to improve the morale of local medical staff who will be in a state of exhaustion and psychological shock. Such teams have a responsibility to be prepared for prompt and efficient action and to go in only if there is a clear need for them. Local information is needed to ensure that the outside help is appropriate and effectively deployed. The existence of experienced and fully equipped teams, capable of immediate availability is essential if a medical response to disasters in other countries is to be considered. Knowledge of the existence and capability of such teams will also enable the coordinators of a disaster relief operation to select the most appropriate help. Although well trained and equipped, the teams should have a low-key approach and respect the authority and sensibilities of local staff.
EisemanB., (1967) Combat Casualty Management in Viet-Nam. 1. Trauma 7 (I), 53. European Dialysis and Transplantation Registry. (1988) Demography of dialysis and transplantation in Europe in 1985 and 1986: Trends over the Previous Decade. Nephrol. Dial. Trunsplant 3, 714. Michaelson M., Taitelman U., Bshouty Z. et al. (1984a) Crush syndrome: experience from the Lebanon War. lsr. 1. Med. Sci. 20, 305. Michaelson M., Taitelman U. and Bursztein S. (1984b) Management of crush syndrome. Restitution 12 (3,141. Rozin J. and Klauser J. M. (1988) New concepts of forward combat surgery. lnjtty 19, 193. Scanlon J. (1988) Planning for peace and war emergencies: learning from 70 years of disaster research. DisasterA4unagementl(2), 3. Williams J. G., Riley T. R. D. and Moody R. A. (1983) Resuscitation in the Falkland Islands campaign. Br. Med. J 286, 775. Wing A. J., Parsons F. M. and Drukker W. (1983) Dialysate regeneration. In: Drukker W., Parsons F. M., Maher J. F., eds. Replacementof Renal Functionby Dialysis. Boston: Nijhoff, 323.
References Bywaters E. G. L. and Beall D. (1941) Crush injuries with impairment of renal function. Br. Med. J 1, 427.
Requestsfor reprintsshould be u&r& to: J. E. Tatter&, Renal Unit, Lister Hospital, Coreys Mill Lane, Stevenage, Herts SGl4AB, UK.
Printed in Great Britain
Acute haemodialysis earthquake disaster
25
during the Armenian
J. E. Tattersall’
N. T. Richards’
M. McCann’
Research Registrar
Honora y Senior Registrar
Sister
T. Mathias ’
A. Samson2
A. Johnson’
Sister
Sister
Chief Technician
‘Renal Unit, St Bartholomew’s Hospital, London, UK 2Renal Unit, St Thomas’s Hospital, London, UK
On the 7 December 7988 an earthquake sfruck a densely populated region in northern Armenia. Up to 50 000 people “were hilled and many thousands were seriously injured. At least 385 of these casualties developed acute renal failure seconday to crush syndrome and required dialysis. 7k Armenian renal unit at Yerevan, in common with units elsewhere, was already oversfretckd to cope with fk dialysis requirements of their patients with chronic renal failure before fk earfhquake. Most of tk patients requiring dialysis were transferred to other hospitals in tk USSR but 120 patients remained in Y&van. tk majority at tk regional renal unit, overwklming tk resources. We assisted by taking a team of dialysis personnel, equipped with portable haemodialysis machines, to Yerevan. We performed 57 haemodialysis sessions and treated 15 patitwfs, 13 of whom ultimately survived.Valuable lessons were learnt about tk medical management of disasters abroad.
Introduction On the 7 December 1988, at 11:20 local time, a severe earthquake struck a densely populated region in north Armenia. Three major towns and several villages were affected. The worst damage was in the town of Spitak which was almost completely destroyed. The Armenian second city and main cultural centre, Leninakhan, was 80 per cent destroyed. The earthquake struck at a time when most people were indoors. The initial shock was followed after 4 min by an aftershock which caused buildings left standing to collapse onto people who were in lower floors or in the street immediately outside the buildings, attempting to escape. Up to 50000 people died and some thousands of survivors were seriosuly injured by crushing. Crushed muscles release myoglobin which is eventually concentrated in the renal tubules. The patient also loses large volumes of fluid into crushed muscles. This combination of volume depletion and myoglobinuria causes acute renal failure (Bywaters and Beall, 1941) and is preventable by early volume replacement and/or amputation of crushed limbs (Michaelson et al., 1984a, b). In the confusion following the earthquake, many of the crushed survivors did not 0 1990 Butter-worth & Co (Publishers) Ltd 0020-1383/90/010025~4
receive this optimal treatment and developed acute renal failure. This type of renal failure is self-limiting and, if dialysis is required, it is usually only for a period of 2 weeks or less. Complete recovery of normal renal function is usual. The USSR does not report statistics relating to the treatment of renal failure in their country, but it is likely that their situation is similar to the Warsaw pact countries of Eastern Europe which are known to dialyse only about 40 per cent of those patients who require it (European Dialysis and Transplant Association Registry, 1988) due to a severe shortage of equipment and the hard currency required to import disposables. The Republic of Armenia had one dialysis unit serving a population of about three million. This unit had eight haemodialysis machines which were fully occupied in the treatment of 70 patients who had chronic renal failure before the disaster. As a result of the earthquake, at least 385 injured survivors developed renal failure and completely overwhelmed local dialysis facilities. The majority of these patients were transferred to other parts of the USSR for treatment but 120 remained in Yerevan, the Armenian capital.
The British response By the 4th day after the disaster, it became apparent that thousands of survivors had developed acute renal failure. Many of these would require dialysis and the Soviet authorities appealed for outside help, including dialysis equipment and personnel. At this time, the only British team in existence capable of providing a mobile dialysis team was a Royal Air Force unit but this was unacceptable to the USSR. By the 5th day of the disaster, a number of British renal units had donated 23 portable haemodialysis machines and some of these units had personnel standing by. A charity, Aid Armenia, arranged collection and transportation of the machines and bought disposable items sufficient for 1000 dialysis sessions. Nineteen of the machines and other medical supplies left Heathrow airport for Armenia that
26
Injury: the British Journal of Accident Surgery (1990) Vol. 21/No.1
same evening. A mobile dialysis team was organized in less than 24 h by St Thomas’s Hospital, in association with Aid Armenia. This team was equipped with four dialysis machines, disposables for 100 dialysis sessions, drugs, access catheters, one doctor, two nurses and one dialysis engineer. Following a request from the Soviet Embassy in London on the evening of the 5th day, a doctor and a nurse from St Bartholomew’s Hospital Renal Unit also prepared for departure. The two teams met at Heathrow airport the following morning. At this stage we believed that we would be treating patients in Moscow. The combined team and equipment departed from London on the 6th day after the disaster and arrived in Yerevan via Moscow on the following day. All transportation, visas and accommodation had been provided, free of charge, by the Soviet authorities. A further 2 days were spent locating and installing equipment before the first patients were treated on the 9th day after the disaster. We were given space in an X-ray suite in the All Union Surgical Scientific Centre (Fiere I). This hospital contained the only existing renal unit in Armenia and had been designated as the referral centre for crush syndrome and renal failure resulting from the disaster. We performed 57 dialysis sessions on 15 patients over a o-day period. The haemodialysis system we selected was the ‘Sorb/Redy’ type which is portable and simple to operate. In Britain, they are used by haemodialysis patients for holiday dialysis, often in hotel rooms. The system uses 5 litres of dialysate which circulates in a closed loop between the dialyser and a special cartridge which removes wastes (Wing et al., 1983). This avoids the need for a purified water supply required by other types and proved particularly suitable.
Other dialysis teams Of the 120 patients with acute renal failure remaining in Yerevan, 40 were treated ‘conservatively’ and 24 were treated by the Soviet army at a military hospital. This left 56 patients to be dialysed in the Yerevan renal unit. Armenian staff, supplemented by personnel from elsewhere in the USSR, treated 21 of these patients (in addition to their 70 long-term patients) using existing equipment. A team from West Germany arrived in the renal unit on the 4th day after the disaster and treated 20 patients. They had chartered a 747 aircraft and brought with them 12 modem single-pass dialysis machines, two water treatment
Figure 1. British ‘renal unit’ in Yerevan.
plants and 4 tonnes of blood lines and other disposable items. The equipment remained in Yerevan after the German team had left and was installed in place of the original dialysis equipment. Belgian and Dutch teams, in association with the intemational medical organization ‘Medecins Sans Frontiers’, also dialysed small numbers of patients with acute renal failure arising in other Yerevan hospitals. This group continues its work in Yerevan and has set up a new dialysis unit.
The patientsand their treatment We treated 15 patients (ages o-65 years), all of whom had acute renal failure due to crush syndrome and had been evacuated within the first 24 h of the disaster. AU had severe limb trauma, two had fasciotomies and four had above-knee amputations (one bilateral). There were also two spontaneous abortions, one ruptured bladder, one ruptured bowel and two spinal injuries with paraplegia. Many of the wounds were infected. Patients tended to be volume depleted and there was often a large loss of serum from wounds. The patients had received inadequate volume replacement due to a shortage of human plasma, infusion sets and cannulae. Most of the patients were on donated ceftazidime in doses inappropriately high for patients with renal failure and three of these had rashes which settled on stopping the drug. Other adverse features included delayed surgical treatment to wounds and infrequent dressing changes due partly to a shortage of strong analegesics. We treated all patients with daily haemodialysis. This gave us the opportunity to supervise fluid balance. Initial vascular access employed Scribner shunts inserted by the Soviet surgeons, but many of these clotted and the supply of shunts ran out. Therefore, we tended to use double-lumen central venous lines we inserted ourselved under local anaesthetic. We treated infections with vancomycin and gentamycin which are given infrequently in renal failure and we could give all doses ourselves at the time of dialysis. Pethidine was given to any patient in pain. Four of our patients required blood transfusions. Eight patients treated by other teams had had severe transfusion reactions, two of which were fatal. We therefore transfused only after performing bedside cross-matching. Of the 15 patients we treated, eight had recovered their renal function by the time we left, one had died and six were still oliguric. Ultimately, IS of the 15 patients we treated recovered with normal renal function and two died.
Figure 2. Bed-side haemodialysis of an infected patient in the surgical ward.
Tattersall et al.: Acute haemodialysis during the Armenian earthquake
After 5 days working in the relatively protected area we had set up as our ‘renal unit’, we were asked to dialyse three infected patients at the bedside on a surgical ward (Figure 2). The suffering, despair and smell of infected tissue we encountered here was difficult to cope with. Local staff were demoralized by overwork, sleep deprivation and shortages of analgesics and items for basic medical care. During the 4 days we worked on this ward, we provided analgesia, changed dressings and spent a considerable amount of time talking to relatives, patients and staff. We also provided advice and training in the use of dialysis equipment and access. We found the Soviet medical and nursing staff were very keen to learn about our techniques and we took part in ward rounds. Language was not a problem as many of the staff spoke English and there was a supply of willing translators.
Lessons learned The presence of foreign medical teams in a disaster area is not necessarily a great advantage. In our case, we contributed towards saving the lives of 13 young people who might otherwise have died. This amounts to a symbolic gesture in the context of the disaster, although our presence may have resulted in other, less easily measurable benefits. Against this must be set the expense (at least f 160,000) and the use of resources in the disaster area. It is therefore necessary that future medical missions of this type only attend if there is a clear need and that the team is properly equipped and trained to maximal efficiency. The inevitable confusion following a major disaster was increased by inappropriate assistance from abroad. This was due to a serious lack of information. We had no advance knowledge of the kind of work we would be doing or even where we were going and, as a result, some of our equipment was inappropriate. There was also a lack of information on the foreign medical teams. The Soviet authorities often had no idea of what kind of assistance they were getting until after the team had actually arrived. This made coordination and effective deployment of the teams virtually impossible. Many of the problems stemmed from the fact that most of the foreign medical teams were not in existence before this disaster and so lacked experience and organization and their capabilities and composition were unknown. If we are to be of any use in future disasters abroad, we must have our teams prepared, equipped and organized before the disaster. An appropirate response must be planned by personnel who can get to the disaster rapidly and have information on the potential aid teams as well as the conditions at the disaster site. Official requests for assistance had stressed the need for ‘high-tech equipment but we found that there was a more pressing need for basic items such as syringes, needles, etc. As a result, we were well stocked with dialysis equipment but lack analgesics, plasma and buckets (needed for filling our dialysis machines with water). In the event we were able to obtain items we needed from other foreign medical teams but we were clearly wrong to rely on the availability of any equipment in the disaster area. Many of the haemodialysis machines donated by British hospitals were not in working order or lacked essential attachments such as blood pumps. There was no time to check equipment before leaving. Also, much of the equipment was lost due to the enormous volume of (largely inappropriate) donated equipment accumulating in Yerevan. Some of our equipment and personal baggage was removed
27
from our aircraft to make way for a donated CT scanner which was deemed more important! Fortunately, the St Thomas’s team had transported a core of essential equipment and machines, known to be in working order, as baggage’ which came with us on the same aircraft. It was helpful to have packed equipment in such a way that each pack contained a mixture of all items needed, so that even if packs were lost, all essential items would still be present in the remaining packs. At the time of a disaster, personnel are under stress and this is not the right time for a mobile medical team to select and pack equipment. It is essential for us to be ready for future disasters by having comprehensive packs of equipment prepared in advance and stockpiled, ready for immediate use. This will save time and reduce error when they are needed. We found that an important aspect of our work was in simple procedures such as putting up drips, providing analgesia and comforting patients. We felt that our presence improved morale and that it was helpful for the local medical staff, who were suffering from exhaustion and psychological shock, to be supported by people who were not so closely connected with the disaster. In this situation, it is tempting to assume a superiority over the host medical teams. This causes resentment and can negate any beneficial effect of the team’s presence. A disaster is not the best time to introduce new techniques, particularly if done in a patronizing manner. The ‘visiting’ team must work under their host’s supervision as helpers rather than saviours. This should be recognized in the preparation and training of future disaster teams. There are long-term implications of the medical aid to Armenia. Before the earthquake, Armenian medical staff had been isolated from the rest of the medical world. Now, they are using modem medical equipment, including disposables, for the first time. Donated haemodialysis machines remaining in Yerevan after the foreign teams departed have replaced original equipment. These machines are of a type totally unfamiliar to Armenian staff and represent an overnight advance in medical technology equivalent to 20 years’ development. The new machines allow greater numbers of patients with chronic renal failure, not resulting from the disaster to be treated. This has created a sudden and long-term requirements for increased numbers of skilled staff. The maintenance and supply of disposables for this equipment (which must be imported from the West) will cause problems in future when the donated stocks run out.
Conclusions Experience of the Vietnam war has led to a strategy for coping with large numbers of casualties (Eisman, 1967). This requires rapid resuscitation and first aid, usually performed in the field by non-medical personnel, followed by evacuation to a functioning hospital outside the immediate combat area (Rozin and Klauser, 1988). Evacuation and definitive treatment can be delayed up to 24 h but the initial resuscitation can not. This principle was refined and used successfully during the Falkland Islands war where the combat troops themselves carried out the resuscitation (Williams et al., 1982). Analysis of past disasters reveals that the combined effects of the destruction and overload of communication systems precludes outside teams appreciating the scale of the disaster, let alone arriving in time to be of any use. In practice, the first response is given by workers already on the spot or in the immediate vicinity at the time of the disaster (Scanlon, 1988). Furthermore, the
Injury: the British Journal of Accident Surgery (1990) Vol. Zl/No.I
28
influx of foreign teams inappropriately equipped and too late to be of any use will waste resources and increase confusion. Our role in assistance in this first response may be more effective if it is limited to perfecting our own local disaster management plans, which can then be used as an example for other countries. However, it may be practical for foreign teams to provide specialized assistance at a later stage to treat delayed complications such as renal failure. Outside medical teams may also help to improve the morale of local medical staff who will be in a state of exhaustion and psychological shock. Such teams have a responsibility to be prepared for prompt and efficient action and to go in only if there is a clear need for them. Local information is needed to ensure that the outside help is appropriate and effectively deployed. The existence of experienced and fully equipped teams, capable of immediate availability is essential if a medical response to disasters in other countries is to be considered. Knowledge of the existence and capability of such teams will also enable the coordinators of a disaster relief operation to select the most appropriate help. Although well trained and equipped, the teams should have a low-key approach and respect the authority and sensibilities of local staff.
EisemanB., (1967) Combat Casualty Management in Viet-Nam. 1. Trauma 7 (I), 53. European Dialysis and Transplantation Registry. (1988) Demography of dialysis and transplantation in Europe in 1985 and 1986: Trends over the Previous Decade. Nephrol. Dial. Trunsplant 3, 714. Michaelson M., Taitelman U., Bshouty Z. et al. (1984a) Crush syndrome: experience from the Lebanon War. lsr. 1. Med. Sci. 20, 305. Michaelson M., Taitelman U. and Bursztein S. (1984b) Management of crush syndrome. Restitution 12 (3,141. Rozin J. and Klauser J. M. (1988) New concepts of forward combat surgery. lnjtty 19, 193. Scanlon J. (1988) Planning for peace and war emergencies: learning from 70 years of disaster research. DisasterA4unagementl(2), 3. Williams J. G., Riley T. R. D. and Moody R. A. (1983) Resuscitation in the Falkland Islands campaign. Br. Med. J 286, 775. Wing A. J., Parsons F. M. and Drukker W. (1983) Dialysate regeneration. In: Drukker W., Parsons F. M., Maher J. F., eds. Replacementof Renal Functionby Dialysis. Boston: Nijhoff, 323.
References Bywaters E. G. L. and Beall D. (1941) Crush injuries with impairment of renal function. Br. Med. J 1, 427.
Requestsfor reprintsshould be u&r& to: J. E. Tatter&, Renal Unit, Lister Hospital, Coreys Mill Lane, Stevenage, Herts SGl4AB, UK.
