Introduction

After the earthquake for a number of hours, the great magnitude of the disaster could not be estimated. Because of the damage to communication and transportation equipment, no information from the quake area could be received until later in the morning. As almost all medical centers and units had been damaged and the medical teams from the surrounding towns failed to be organized properly after the quake, the injured patients were transported to the surrounding towns. The Armed Forces had been organized first and injured patients were taken from the wreckage and transported by air and sea to 1 ^st Army Helicopter Area and Haydarpa?a Seaport respectively. Especially in the first 72 hours, most patients were transported to Istanbul from the disaster area only by military vehicles since other medical centers locally had not been organized; a significant number of patients were brought to our hospital. After the first 72 hours as the number of survivors taken from the wreckage decreased and other medical centers began to be organized, the patients brought to our ED decreased significantly. In the first 24 hours, 347 injured patients, between 24 and 72 hours 112 patients, and after 72 hours 73 patients were hospitalized following first aid in the ED. Especially in the first 48 hours, because so many injured patients were brought to the ED and the operations rooms and clinics were inadequate, about 100 patients were transported to other centers by ambulance.

Materials And Methods

After the earthquake, the ES and hospital charts of all patients were reviewed retrospectively. Data were collected from all presenting patients' charts from 5:47 AM August 17 1999, to 12:00 AM August 23 1999. Patients with injuries related to the earthquake were entered into this study. Illness related to the earthquake was included which was defined as a medical condition brought on as a result of the earthquake, such as acute gastroenteritis or palpitations, or preexisting medical conditions, such as hypertension and diabetes, exacerbated by the effects of the earthquake. At the peak time, patients were registered with a numbered medical chart and a corresponding identity necklace. At a later stage, all patients' data were entered into the computer records. Patients with trauma were recorded to a computer programmed according to age, sex, and medical and surgical setting, underlying diseases, risk factors and mortality rates. Because autopsy could not be performed on all deceased after the earthquake, the causes of mortality were based on the laboratory and clinical findings of the patients.

Patients' charts were reviewed for the time of arrival, the treatment provided in the ES, and diagnoses according to the International Classification of Disease, Ninth Revision (ICD-9).

Results

The age ranges of hospitalized patients (312 males, 220 females) were between 2 and 90 years (mean age: 32). In the first 24 hours, 347 injured patients, between 24 and 72 hours 112 patients, and after 72 hours 73 patients were hospitalized following first aid in the ES. Especially in the first 48 hours, because so many injured patients were transport to the ES and the operations rooms and clinics were inadequate.

After the earthquake, 532 patients with multitrauma were brought to the emergency room. 152 (28.6%) of the patients were performed emergency surgery. Of the 106 cases with multitrauma, 40 had upper extremity fracture, 24 had lower extremity fracture, 24 had amputated extremity, and 18 had upper and lower extremity fracture. Thirty-one multitrauma patients were with craniocerebral and vertebral injury. Of these, 15 patients were with vertebral injuries at different levels, four with cranial fracture, one with traumatic subaracnoid bleeding, one with radial nerve injury and remaining 10 cases were with contusio cerebri. Nine injured patients were with intraabdominal organ injury. Of these one patient was with hepatic rupture, one with splenic rupture, two with diaphragm rupture, one with descending colon rupture and two were with renal and urinary bladder injury. Five patients were with obstetric and gynecological trauma (one of them cesarean and left food amputation). In addition, 11 multitrauma patients were with thorax trauma with different severity. Of these six patients were with pneumothorax and five with hemopneumothorax. In addition, one patient was with panfacial fracture and one with urinary bladder rupture. Other 363 (70.4 %) injured patients with mild injuries at different sites were hospitalized for observation. All of the patients with trauma are summarized in Table 1.

Figure 1

Table 1: Analyzing of the patient with trauma Type

We identified 106 patients with crush syndrome. These patients consisted of 62 men and 44 women with a mean age of 47.4 +/- 19.8 (SD) years, ranging from 2 to 90. Time trapped ranged from 3 to 98 hours (9.0 +/- 13.0 hours). The injury was exposed predominantly on the upper and lower extremities (40 patients, 37%), followed by the lower extremities (39 patients, 37 %), and the upper extremities (27 patients, 26%). Limb fractures and abdominal injuries were the most frequently associated injury. Crush syndrome resulted in a total of 13 deaths (2.1%). Patients with trunk compression and/or with abdominal injury had a higher mortality rate. Thirty-one patients were treated by hemodialysis. The number of fasciotomy procedures was 77. Hyperbaric Oxygen (HBO) Therapy was applied to 52 critical injured patients for enhancing oxygen saturation of devitalized and ischemic tissues, decreasing of inflammation and infection and increasing of respond to therapy. It was applied to victims under condition two-four absolute atmosphere pressure (ATA) in Hyperbaric Oxygen Therapy Services of our hospital.

After the earthquake, the patients that were brought to the emergency service were not only from the affected area but also from Istanbul who were jumped down because of the panic. They were 12 patients with minor injuries.

Apart from these surgical cases, in a week’s time numerous patients with hypertensive, cardiac and psychiatric complaints attended to emergency department. Of these 85 hypertensive patients, four patients were with hypertensive encephalopathy and 19 with hypertensive urgency. 38 patients with cardiac emergency were brought to the emergency department. Of these five patients were with acute myocardial infarction; of them three from the disaster region. One patient who was transported by air was dead at the emergency room. In a week’s time after the earthquake three patients with somatization, 10 with anxiety disorders, 13 patients with phychiatric disorders admitted to emergency department and advised to attend on an outpatient basis. All of the patients are summarized in Table 2 according to ICD-9 codes.

Figure 2

Table 2: Diagnostic categories of patients in the initial 7 days after the earthquake.

A total of 60 patients (9.49%) died. Of these, 39 patients (6.2%) died within 48 hours due to complications of hypovolemic shock and multiorgan failure without infection. In the first 24-48 hours, 27 (4.3%) patients were dead because of bleeding, hypovolemia and vital organ injury on the arrival to the hospital or at the emergency room despite the emergency procedures. In addition, 33 of the hospitalized patients in days were dead because of acute renal failure, crush syndrome, sepsis, multi organ failure, adult respiratory distress syndrome and major organ failure. At the emergency department, the mortality rate was highest between 24 and 48 hours. The mortal cases were the ones that should have been treated urgently at the disaster region that should have not been transported because of the vital organ injuries and the ones that have not been evaluated and treated appropriately.

The Problems After The Earthquake

The major problem was the transport of the patients to the hospitals. As the main roads were destroyed, military ships and helicopters of the Armed Forces performed the transports of the injured patients. Because of the fire in the ?zmit Refinery the transport of patients by sea was delayed for 6-8 hours. Another problem was the transport of patients from collection zones to hospitals. Military vehicles and ambulances, official and private, solved the problem. In addition, wagon cars were used for transport. In the first 24 hours only military vehicles transported most patients from the disaster area, and a significant number of patients were brought to our hospital. The great number of patients exceeded the capacity of the ED and caused various problems. The major difficulty was to determine the priority of the patients to have appropriate therapy, as no first aid and triage had been done in the disaster area. Lack of personel experienced in disaster medicine and triage was another important problem. Difficulties with the registration of patients, the insufficient area for medical procedures and first aid in the ED were major problems. In addition, failure of communication with the disaster area in the first 6 hours, and the increased presentation of patients to the ED whom were not directly affected by the earthquake were the major problems that were faced in the first 24 hours. One another problem was that the personnel from other departments who were in the ED to help caused overcrowding.

Triage is the process to determine the priority of the treatment of patient and is obligatory in such disasters. After the Marmara earthquake triage could not be performed on patients within the first 24 hours in the disaster area and in the collection sites, so all patients were initially evaluated in the ED. Consequently, failure in registration and management of patients was observed. A medical team composed of two doctors and two nurses were sent to the quake region and collection sites to evaluate the patients for the triage process. In addition, some patients were transferred to the surrounding hospitals. This lessened confusion and patients were evaluated in a less crowded place.

The ED was not large enough and the great number of victims was beyond the ED capacity. Therefore, the garden next to the ED was prepared and illuminated for night, and portable equipment was carried to the garden. The patients with life-threatening injuries were kept in the original ED. The importance of portable equipment was confirmed by the quake. The chief of pharmacy and clinics obtained the medical equipment. The medical equipment needed was resuscitation sets, defibrillators, monitors, portable X-ray and sonography, and sterilizers. As patients in hemorrhagic shock were numerous, the need for plasma expanders and blood components increased significantly. Blood and blood components were provided after cross-match for seriously injured patients. So the blood bank was moved to the emergency laboratory. Because of the volunteer donors there was no problem in obtaining sufficient blood. The most needed medical equipment was resuscitation drugs and catheters. Also more cervical collars, other fixators and plaster casts were needed for the patients with extremity or vertebral fractures.

The failure in communication especially in the first 6 hours and registration problems in the first 24 hours were major problems. The problem in communication was solved by wireless and military communication systems. Adding more staff solved the problem with registration. The problem of registration of patients with no identification and those unconscious and dead was solved by fingerprinting and taking photos. The medical personel worked hard and got very tired, and. therefore, worked in relays.

Discussion

After other disasters, even weaker quakes than Marmara, similar difficulties were faced by the emergency service. The Kobe earthquake in January 1995 caused 6500 deaths and 34900 injuries in Japan and after the quake, the major problem in the emergency room was the confusion because of the overpopulation and failure of communication [₁,₂]. In addition, failure in energy, water sources, air-conditioning system, sterilization and problems in anesthetics gas distribution were the major problems in the emergency room in Kobe University [₂]. In the Loma Prieta quake in California in 1989, 63 patients were killed and 3700 were injured, failures of communication, patient transport and registration of the patients were noted [₃]. In the quake in Armenia in 1988, similar problems were observed especially in patient transportation [₄].

Marmara quake thought us two lessons. First hospitals and emergency services should be well prepared for such disasters and first aid should be started in the quake area. Therefore, every medical unit and center should prepare a disaster plan. These plans should be practical, easily understandable, easily applicable and current. Only in that way, can the problems be minimizing. One of the best plans for example is the California disaster plan [₅,₆]. The disaster plan should include the preparations that should be done before the disaster, distribution of the early information about the disaster, and preperations for the first injured patient to arrive at the hospital.

In a disaster plan all units of the hospital should be well coordinated with each other. Extraordinary Condition Management responsible for the planning and practice for the hospital and emergency service directors should set up the disaster response. The Extraordinary Condition Manager should set up teams as interventional teams, management teams and public relations teams (Table 3). The work schedule of these teams should be prepared, the interaction with other teams should be practiced and reserve personnel should be selected a head of time. Extraordinary Condition Management should maintain the plans current, control the equipment and should undertake frequent practice for the personnel. Otherwise, the things that had been done had been only plans on the papers.

Figure 3

Table 3: The Chart of the Extraordinary Condition Management

The plans of these teams should include general precautions, work schedule, hospital care, equipment, transport, registration, communication and security. General precautions should include resistance of the building of the hospital to fire and quake, transport, regular traffic, generator for electricity able to safely, and water reservoir. In addition, after the quake because staff may not be able to safely work within the building, tents and prefabricated buildings and quake resistant special buildings should be taken into consideration. Plans to increase the ED and hospital patient capacity should be decided. Plans should be considered for the medical equipment of the clinics to be given for use by the emergency service when needed. Also plans for additional medical and other personnel to be taken to the hospital should be made. These plans should include the supply of medical equipment when regular pathways are broken. Cooperation with the police is essential for traffic control and use of alternative roads. Plans to maximize the number of ambulances should be made. In the “Marmara Quake” as the main roads were destroyed, especially in the first 48 hours the majority of the patients were transported by ships and helicopters of the Armed Forces. Thousands of injured people survived due to early transport air and sea. As in Kobe [₇], Erivan [₈] and Taiwan Chi-Chi [₉] earthquakes, air transport was most important as main roads were destroyed. Therefore, helicopter peds should be near the hospitals. In addition, in cities like Istanbul, which is a port, plans for alternative sea transportation should be considered. Use of hospital ships for such disasters, should be considered. Also as communication systems would be destroyed after quakes, alternative communication systems should be planned. In the Marmara quake in the early hours, the only method of communication was the military wireless system and satellite based mobile telephones, and this was reported at the Taiwan Chi-Chi earthquake too[₉]. In the confusion of a disaster, ED registration is another problem: so extra personnel should be planned for such disasters: Registration should utilize 2 forms, started at triage, followed in the ED, one with the patient and the other with the registration officer. The registration form should include the identification of the patient, address and telephone number, physical exam findings, injured systems and severity of the injury. Also laboratory and x-ray findings, blood group of the patient, and treatments done by the doctor and nurse should be noted. If the patient was dead, fingerprints and photos should be use to identify the patient. In addition, video records would be helpful in identifying the patients and recording the events.

In the Loma Prieta earthquake, Thiel et al [₁₀] reported that during a massive earthquake with large numbers of casualties, the greatest demand for medical attention occurs during the initial 24- to 48-hour period after the disaster. Henderson et al [₁₁] has stated that after a natural disaster, a hospital ES can expect to see an increase of 3 to 5 times the number of patients normally seen in the ES. In the experience of Taiwan's earthquake, the number of patients admitted to the ES increased 1.8-fold in the first 3 days after the earthquake. The rate of increment was greater in the initial 6 hours by 6.1 times compared with that before the earthquake. Their result was inconsistent with the study by Noji et al [₁₂] on the Soviet Armenian earthquake and the study by Pointer et al [₁₃] of the Loma Prieta earthquake in that the peak patient admission did not occur during the second to fifth day after the earthquake. Their result was similar to the experience of the Hanshin earthquake in that the peak in the demand for emergency patient care occurred 2 to 8 hours after the earthquake. [₁₄]

As the first information about the disaster is received, as extraordinary Condition Manager and personnel on duty should undertake first precautions. First, calling additional personnel to duty is essential and in three levels related to the severity of the disaster. In the first level the personnel of the hospital are called for the second level additional other than the hospital personnel are called for, the third level volunteers are also called. In the Marmara quake first and second level personnel were recruited to the hospital. Also a lot of volunteers presented to the hospital and the emergency service to be a blood donor or just to help. For a disaster the stable patients should be discharged. Also, in order areas for therapy should prepared, security arranged, the morgue enlarged, blood, plasma, vaccine, food, provided and information given to the press and visitors. The hospital patient care areas may not be enough, so that gardens, fields, tents and prefabricated buildings should be considered.. These places should be large enough and resistant to the after quake shocks, and have, water and electricity supply. These places should be large enough for medical tools and equipment to treat cardiopulmonary arrest and have portable devices for diagnosis and therapy, areas for fractures and victims of fire. Hospital morgues may be insufficient in such disasters. Therefore, additional refrigerated secure areas should be planned. Cooler trucks and ice stores could be used. After a disaster obtaining blood, plasma and vaccines are major problems. Especially vaccine and serum against tetanus and perfringens is very important. Ensuring adequate food supply is another important problem for patients and hospital personnel.

When the injured patients begin to arrive at the hospital, the patients should be evaluated and grouped according to the “extraordinary condition plan.” As planned before, action teams should be on duty.

To minimize mortality and morbidity after a disaster, planning and being ready is essential. New manuals must be developed incorporating the key points garnered from experience and be ready for use immediately. It is the time, for each hospital to seriously rethink the measures it should take to deal with disasters.

If the hospitals and the emergency services in the area affected by the earthquake are not ready for such disasters, serious problems will be observed. So the question for earthquake response “are we ready?” should be asked.