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N Roy. Disaster Tourism, Fly-by-night Operations And Other Travelogues From The Bhuj Earthquake Front. The Internet Journal of Rescue and Disaster Medicine. 2000 Volume 2 Number 2.
The last place I was to learn a lesson in medical ethics was in the Bhuj Earthquake scenario. A reconstruction of the events of the Earthquake from day One has its own story to tell...
A piece out of the Age of Voltaire, by Will and Ariel Durant, which though three centuries old, couldn’t possibly describe the scenes of the Gujarat Earthquake more accurately:
“At 9.40 am on all ‘All Saints’ Day, Nov. 1, 1755, the earth shrugged its shoulders in Portugal and N. Africa; in six minutes thirty churches and a thousand houses were demolished, 15,000 people were killed, and 15,000 were fatally injured, in one of the most picturesque capitals in the world. There was nothing nprecedented in such wholesale slaughter, but there were some attendant circumstances that troubled the theologians. Why had the Great Inscrutable chosen so Catholic a city, so hold a festival, and such an hour, --when all pious citizens were attending the Mass? And why had he spared, amid the general ruin, the house of Sebastiao de Carvalho e Mello--the Marqwuies de Pombal--the ruling minister who was in all Europe the most fervent enemy of the Jesuits?
In an angry reaction against his own early optimism V composed (1756) his greatest poem--”On the Lisbon Disaster, or An Examination of the Axiom ’All is Well’“.
“Oh, miserable mortals, grieving earth!
Oh, frightful gathering of all mankind!
Eternal host of useless sufferings!
Ye silly sages who cry, “All is well,”
Come, contemplate these ruins horrible,
This wreck, these shreds and ashes of your race;
Women and children heaped in common death,
These scattered members under broken shafts;
A hundred thousand luckless by the earth
Devoured, who, bleeding, torn, and still alive,
Buried, beneath their roofs, end without help
Their lamentable days in torment vile!
To their expiring and half-formed cries,
The smoking cinders of this ghoulish scene,
Say you, “This follows from eternal laws
Binding the choice of God both free and good”?
Will you, before this mass of victims, say,
“God is revenged, their death repays their crimes”?
(From “The Age of Voltaire” by Will and Ariel Durant, pg. 722. )
Voltaire questioned why cities like Paris and London, which surely had more sin than a pious city like Lisbon, were never attacked by earthquakes. The analogy was close. Kutch which has been reeling in drought for the last two years, now got a “bonus” (in the words of the locals) in the form of an earthquake. But that was not all. Man was to finish God’s incomplete task of destruction.
The last place I was to learn a lesson in medical ethics was in this scenario. A reconstruction of the events of the Earthquake from day One has its own story to tell??
The Earthquake strikes taking down all communication lines. News about the extent of the damage, travels by road away from the epicenter. The survivors quickly realize that there is no way the destroyed city can cope with the casualties. They start to evacuate in every available moving vehicle, carrying the injured and abandoning the immobile and the buried.
The government and the trust hospital doctors working around in the neighboring areas, abandon their posts and stations and rush in with their ambulances and paramedics, carrying a basic set of supplies. Hopelessly equipped (even in normal situations), the first line doctors find themselves inadequate, except to triage the serious patients and advise transfer to facilities downstream. That was the need of the hour. It would be foolish to attempt anything heroic.
Within hours of the quake, at every district hospital, private practitioners move in and man the hospitals to help the casualties. There are hundreds of operations performed through the day and night. Doctors coming in from all parts of the country are told that they are not needed. Most relief teams are told to go elsewhere. At the same time the blood, drugs and implants they bring along are more welcome than them. What were all these surgeries that were done? One would have expected External fixators, Steimann pin insertions, amputations and debridements. Essentially, clean-up jobs, chop-offs and plastering. But instead there were plating of femurs (of 3-year olds!), Austin-Moore head replacements (of 70-yr olds), nailing of tibias and plating of Radius-ulnas. All, elective and cold surgery, which could have waited for days, if not a month, was being done in the mayhem. Surgeons fiddled while Kutch shook. A huge majority of the fractures were compound and contaminated with collapsing mud-walls and cowdung. Most of the patients were women and children. All that metal through their marrow, sent all the muck through virgin tissue. Before the end of the week, there was pus pouring out of the operated sites.
Almost anyone who stayed long enough to see the aftermath of the heroic surgeries, saw more than the quake. Not so strangely, there were wounds which did extremely well. They were operated by the lesser mortals, the Opthalmologists, Paediatricians, Gynaecologists, who turned Orthopaedic Surgeons overnight. They did Guillotine amputations, debridements and put on slabs of Plaster of Paris on all mundane wounds while the great masters nailed bones. All these patients went home without complications by the seventh day. The cursed stayed back with their fancy indwelling metalwork.
And we would like to believe that the Politicians were the only ones getting mileage out of the earthquake and its misery. It was horror tourism at it best. Doctors arrived in hordes, carrying video equipment to capture the graphic display of misery and show them back home. That was an end in itself. Most relief teams arrived with 12-hour commitments, in a hurry to lend their surgical expertise. There were no takers for post operative care. These fly-by-night operators insisted on operating and were gone with their photographs within two hours after surgery, leaving us to take care of their handiwork. The lack of accountability was remarkable. They left a trail of business cards, with degrees and addresses of distant lands, or famous Indian metropolitan cities. They couldn’t let their practices suffer, but they had come to do their bit. The burden of taking them around the wards and being forced to cater to them was the last straw on the camel’s back. The staff who had worked night and day was already at the point of exhaustion. This was the consistent experience across all the centers. Every hospital has similar horror stories to trade.
Surgery is so much fun, that all too often we tend to lose sight of its raison de etre. What is appropriate surgery in a disaster situation is a moot point. With our inherent inability to work as team, whether in hockey or in medicine, this chaos is the inevitable outcome. Coordination, cooperation and preparedness are alien words in our dictionary where medicine is practiced with personal triumphs. Doing the right thing in such situations is a matter of training, experience and humility. I must remark that in the squalor, I met some remarkable people. They took orders from the local superintendent, avoided local politics and were careful of cultural sensitivities. They had no axe to grind and did the dirty work of dressing the wounds. Barring a rare few, most of them were from the University hospitals of India and abroad. They could give their time, commitment and they all followed protocols. They were relieved by fresh groups of well-balanced teams and there was a good system of handover. These are ingredients of the future disaster management squads, to prevent further catastrophes. There is hope for us, if we decide to get organized and cooperate.
Dr. Nobhojit Roy, MD Scientific Officer & Surgeon Bhabha Atomic Research Centre Hospital, Anushaktinagar, Mumbai, 400094, India Ph: +91-22-5563140-41 Email: email@example.com