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Triage of pediatric injuries after the 2008 Wen-Chuan earthquake in China
Journal of Pediatric Surgery (2009) 44, 2273–2277
www.elsevier.com/locate/jpedsurg
Triage of pediatric injuries after the 2008 Wen-Chuan earthquake in China Bo Xianga,⁎, Wei Chengb , Juxian Liuc , Lugang Huanga , Yuan Lia , Lijun Liua a
Department of Paediatric Surgery, West China Hospital, Si-Chuan University, Si-Chuan 610041, China Faculty of Medicine, Nursing and Medical Sciences, Department of Paediatrics, Department of Surgery, Monash Institute of Medical Research, Monash University, VIC, Australia c Department of Ultrosonography, West China Hospital, Si-Chuan University, Si-Chuan 610041, China b
Received 20 July 2009; accepted 31 July 2009
Key words: Earthquake; Children; Disaster management; Triage; Posttraumatic stress disorder
Abstract Purpose: The study aimed to review the effect of modifying triage strategies on the consultation and operation waiting times during the Wen-Chuan earthquake in China in 2008. Method: The triage during the post-earthquake period was categorized into 3 phases. The consultation and operation waiting times were analyzed. Results: Of the 119 admitted children, there were 58 boys and 61 girls. Most of the victims were schoolaged. In phase 1 (24 hours after the quake), the triage waiting time was 78 minutes. The waiting time for pediatric subspecialty consultation was 3.5 hours. There was an additional 7.5-hour delay before operation. In phase 2 (24-72 hours after the quake), senior pediatric surgeons carried out the triage and consultation. The consultation waiting time was reduced to 31 minutes. Four rotating teams operated 24 hours a day. The waiting time for operation was reduced to 4.5 hours. In phase 3 (4-19 days after the earthquake), gas gangrene screening was implemented. The triage waiting times for closed and open injuries were 47 and 64 minutes, respectively. Operation waiting times of 4.4 and 4.8 hours were recorded for closed and open injuries, respectively. Compared to that of phase 1, the waiting times for both consultation and operation of phases 2 and 3 were significantly shortened (P b .05). Most of the (89%) of the injuries were orthopedic traumas with lower limb fracture being the most common injury. Intraabdominal and thoracic injuries were relatively uncommon. Conclusions: (1) Triage by pediatric surgeons in the reception area greatly reduced the delay of treatment and (2) the predominance of orthopedic injuries resulting from the earthquake indicates the focus of medical resource allocation in natural disasters of this type in the future. © 2009 Elsevier Inc. All rights reserved.
Presented at the 42 Annual Meeting of the Pacific Association of Pediatric Surgeons, Hong Kong, China, May 10-14, 2009. ⁎ Corresponding author. Tel.: +86 28 8038 8280. E-mail address: [email protected] (B. Xiang). 0022-3468/$ – see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2009.07.068
The unexpected earthquake on May 12, 2008, in WenChuan, Si-Chuan Province, China, greatly challenged the provincial medical system. The earthquake registered 7.9 on the Richter scale and occurred during school hours, resulting in numerous pediatric casualties. Our hospital was the only major pediatric surgical center close to the epicenter of the
2274
B. Xiang et al.
earthquake. The usual mode of triage in the Accident and Emergency Department in our hospital during this extraordinary disaster resulted in serious delay in surgical intervention. We modified our practice of triage after the initial 24 hours. We compared the key benchmarks of 3 patterns of triage adopted during the post-earthquake period.
1. Materials and methods Between May 12, the day of the earthquake, and May 31, 2008, 213 pediatric victims of the earthquake were
Fig. 1
received in our hospital. One hundred nineteen of them were admitted. Complete medical records were available for this group. The remaining 94 children were discharged after consultation and appropriate treatment, as 95% of them had moderate soft tissue injury alone. This latter group was not included in the analysis. The injuries sustained by the admitted children were categorized into (1) limb injury, spinal and pelvic fractures, (2) abdominal injuries, (3) thoracic injuries, and (4) multiple system injuries. Limb injuries were further subclassified into open or closed injuries, and compartment syndrome. Three triage protocols were implemented.
The flow charts of triage management through the 3 phases of earthquake resuscitation.
Pediatric injuries after the 2008 Wen-Chuan earthquake
2275
1.1. Phase 1: 24 hours after the earthquake (group 1) In accordance with Accident and Emergency Department protocol, pediatric earthquake victims were triaged to the Department of Pediatric Surgery. Pediatric surgical residents further triaged the victims into the appropriate surgical subspecialties.
1.2. Phase 2: 24 to 72 hours after the earthquake (group 2) Because of the dramatic increase in the number of transferred patients, the following modifications of the triage protocol were adopted: 1. To shorten the triage waiting time, the triage was carried out by senior surgeons in the accident and emergency department, instead of surgical residents. 2. To shorten the waiting time for operations, 4 operating teams were formed. Each team, consisting of a consultant and 2 residents, operated around the clock in rotations. 3. To guarantee adequate rest for the operating teams, the postoperative care was carried out by the nonoperating surgical staff.
1.3. Phase 3: days 4 to 19 after the earthquake (group 3) Additional gas gangrene screening and isolation were implemented. Wound swabs were obtained from all open wounds for gram-positive cocci screening (Fig. 1). The data were analyzed using Student t test, with P b .05 being considered statistically significant.
2. Results Of the 119 children admitted into our hospital, 83% presented 48 hours after the earthquake, well beyond the
Table 1 The characteristics of the injured children admitted in each post-quake phase Time injury Case numbers Age (after the Male Female Preschool School (mean ± SD) quake) age Within 24 h 4 Between 24 17 and 72 h After 72 h 37 Total 58
6 24
3 7
7 34
7.25 ± 4.25 9.42 ± 3.47
31 61
16 26
52 93
8.71 ± 3.53
Fig. 2 Categorization of the injuries of patients admitted throughout the different phases after the earthquake.
crucial “golden” resuscitation period. This included a 10-year-old girl who was buried for 105 hours. There were 58 boys and 61 girls with age ranging from 3 months to 14 years. There was no age difference comparing children admitted in group 1, 2, or 3. However, there were significantly more school-aged children than pre-school children in all of the groups (Table 1). Of the 119 children analyzed, bone fractures accounted for most of the injuries. This included 22% upper limb fractures, 49% lower limb fractures, 10% pelvic fractures, and 14% compartment syndrome. There were significantly more orthopedic traumas than other types of injuries (Fig. 2). Hence, fracture reduction and fasciotomies accounted for a substantial proportion of the operations performed. Wound swabs revealed gram-positive cocci in 80% of cases, but there were no positive blood cultures observed. We carried out 63 emergency operations. Details relative to injury classification and intervention are listed in Table 2. There was no mortality among the entire group of 119 children admitted to our institution. Sixty-five percent of the admitted children had from various degrees of psychological stress, manifested by fear, irritability, severe insomnia, hallucination, and compulsive behavior. In phase 1 (n = 10), the average waiting times for triage and pediatric surgical consultation were 78 minutes and 3.5 hours, respectively. The average waiting time for operation was 7.5 hours. In phase 2 (n = 41), the waiting times for pediatric surgical consultation and for operation were reduced to 31 minutes and 4.5 hours, respectively. During phase 3 (n = 68), change of garments and isolation protocol were implemented as there were 48 cases of suspected gas gangrene out of 1583 open wound patients in the adult age group (treated separately). The consultation waiting time increased to 47 minutes and operation waiting time was 4.4 hours. The waiting times for consultation and operation during phases 2 and 3 were significantly shorter than those of phase 1 (Student t test, P b .05) (Fig. 3).
2276 Table 2
B. Xiang et al. Detailed classification of injuries sustained by the pediatric population during the earthquake
Subspecialty
Injury characterization
Orthopedics
Fractures
Upper Limb
Lower Limb
Associated Nerve Injury
Limb compartment syndrome Dislocation General
Pelvic Skull Thoracic spine Brachial plexus Femoral nerve Radial nerve
Shoulder Atlas
Liver fracture Soft tissue injury Hemopneumothorax
Thoracic
Humerus radius, ulnar Clavicle Femur Tibia, fibula Calcaneus Patella
Case number
Management Operative
Nonoperative
12 13 1 23 19 16 2 12 2 4 1 4 2 17
9 10 1 21 14 3 2 1 0 0 0 1 1 17
3 3 0 2 5 13 0 11 2 4 1 3 1 0
1 1 5 4 4
1 0 3 3 3
0 1 2 1 1
3. Discussion
3.1. Earthquake trauma pattern
We have reviewed the triage and resuscitation of 119 pediatric victims of the strongest earthquake in modern China. We altered the routine triage protocol according to the patient volume load. Experienced surgeons were sent to the reception area to carry out consultation. Four operating teams worked around the clock. These extraordinary measures in the face of this extreme natural catastrophe greatly reduced the waiting times for consultations and surgical operations.
The predominance of orthopedic trauma is similar to the pattern of earthquake injuries reported in the literature throughout the world [1,2]. In the children we treated, this injury pattern was observed mainly as a result of collapsed buildings. The earthquake occurred during school hours, and most of the children were inside school buildings at the time. Most of the patients with head injuries were admitted to the neurosurgical unit. Neurosurgery department data showed that cervical fracture and closed head injuries were common. Although open skull wounds were relatively rare, it is possible that many children with this type of injury did not survive the initial trauma and, therefore, were not brought to our attention. In this regard, our data analysis may not represent the complete spectrum of earthquake injuries which occurred during this disaster.
3.2. Lessons learned
Fig. 3
The effect of triage adjustment on the waiting time.
3.2.1. Golden hours of resuscitation Change of triage practice in our institution enabled us to cope with large number of transferred trauma patients. It effectively reduced the waiting time for both consultation and operation. It may have also minimized the development of gas gangrene. Yet, review of our experience showed that, of the 1324 adult and pediatric admissions into our hospital, only 5.89% were admitted within the first 12 hours after the earthquake. The low mortality rate in our cohort of 119 pediatric patients reflects the nature of the transfer pattern. Those who were admitted into our hospital most likely
Pediatric injuries after the 2008 Wen-Chuan earthquake
2277
represented a selected group of children who survived the initial impact of the earthquake. Wen-Chuan is a mountainous area with many peaks exceeding 2500 m in altitude. Many valleys are more than 1800 m deep. The earthquake completely interrupted most of the roads and telecommunication. Many critically injured children died at the scene before transport was possible. Official government figures include 5335 school-aged children who died in the WenChuan earthquake. The extreme terrain at the epicenter and lack of adequate helicopter airlift resource prohibited the timely evacuation of most of the severely injured children during the critical first few hours after the earthquake. Employment of helicopter transportation during the second 24-hour period enabled more effective patient transport, and 22.5% of the victims were admitted during the next 2 days [3] (24-72 hours after the earthquake). These findings suggest that improved logistic preparation, mass casualty training, and surge helicopter deployment capability to facilitate more timely and volume-adequate evacuation immediately after an earthquake in the future could substantially reduce morbidity and mortality [4-6].
quiet environment. In addition, group play therapy in conjunction with a program consisting of appropriate exercise and adequate nutrition was carried out. A small group of children was unresponsive to this management protocol and some patients demonstrated a hostile attitude toward treatment. One-on-one daily consultations were instituted for those children who expressed aggressive behavior. Of the cohort with PTSD, no child displayed any signs of permanent psychological trauma on discharge. These children were followed clinically on a monthly basis for the first 6 months after discharge and at 2-month intervals after that. Most have returned to their community and restarted school. Interestingly, the overworked medical staff also displayed various degrees of depression, attention deficit, fatigue, and insomnia. We organized 3 talks for the medical staff to provide guidance and to reduce the psychological stress impact on the staff.
3.2.2. Capacity surge The sudden requirement to provide for the urgent surgical needs of so many injured children placed an unusual burden on our health delivery system. The surge of bed demand (usually capacity of 124 beds) was met by the addition of 70 beds. Some stable in-patients, admitted before the earthquake, who had adequately recovered from illness, volunteered for discharge from the hospital. Four groups (9 per group) of pediatric orthopedic and general surgeons were mobilized from the rest of the country to join the effort of Hua-Xi Hospital. Within 24 hours of the earthquake, we identified the increasing trend of delay in triage and operations. The change of triage practice and formation of the operating teams to work around the clock greatly improved the delivery of medical care. To better understand the injury characteristics and management requirements particular to this type of disaster, we have established a central data bank and have collected more than 5000 cases of pediatric earthquake victims from multiple centers in the earthquake affected area.
3.3. Psychological trauma The earthquake also traumatized the victims psychologically, especially the pediatric victims [7-10]. Among the 119-child cohort, 65% displayed significant posttraumatic stress disorder (PTSD) consisting of anxiety, fear, fear of darkness, and insomnia. Therefore, on the third day after the earthquake, the South West Psychological Health Center established a “Psychological Treatment Center” in the pediatric surgical ward. Children diagnosed with PTSD were treated by trained psychologists using a protocol that included daily specialized group counseling conducted in a
3.4. Conclusion Our experience demonstrated that adaptation of triage protocols, mobilization of additional personnel resource, and increased helicopter availability for the evacuation and transport of injured children could greatly improve the relief work involving natural disasters in the future.
References [1] Bozkurt M, Ocquder A, Turktas U, et al. The evaluation of trauma patients in Turkish Red Crescent Field Hospital following the Pakistan earthquake in 2005. Injury 2007;38:290-7. [2] Helminen M, Saarela E, Salmela J. Characterisation of patients treated at the Red Cross field hospital in Kashmir during the first three weeks of operation. Emerg Med J 2006;23:654-6. [3] Gao H-G, Qin Q, Lin D-J, et al. Triage algorithm analysis of 2621 patients 3 weeks after Wenchuan earthquake. Chin J Evid Based Med 2008;8(9):718-21 [Chinese]. [4] American Academy of Pediatrics Committee on Pediatric Emergency Medicine, American Academy of Pediatrics Committee on Medical Liability, Task Force on Terrorism. The pediatrician and disaster preparedness. Pediatrics 2006;117:560-5. [5] Olympia RP, Wan E, Avner JR. The preparedness of schools to respond to emergencies in children: a national survey of school nurses. Pediatrics 2005;116:e738-45. [6] Cicero MX, Baum CR. Pediatric disaster preparedness: best planning for the worst-case scenario. Pediatr Emerg Care 2008;24:478-81 [quiz 482-4]. [7] Williams R, Alexander DA, Bolsover D, et al. Children, resilience and disasters: recent evidence that should influence a model of psychosocial care. Curr Opin Psychiatry 2008;21:338-44. [8] Jones L. Responding to the needs of children in crisis. Int Rev Psychiatry 2008;20:291-303. [9] Betancourt TS, Khan KT. The mental health of children affected by armed conflict: protective processes and pathways to resilience. Int Rev Psychiatry 2008;20:317-28. [10] Chandra V, Pandav R, Bhugra D. Mental health and psychosocial support after the tsunami: observations across affected nations. Int Rev Psychiatry 2006;18:205-11.
www.elsevier.com/locate/jpedsurg
Triage of pediatric injuries after the 2008 Wen-Chuan earthquake in China Bo Xianga,⁎, Wei Chengb , Juxian Liuc , Lugang Huanga , Yuan Lia , Lijun Liua a
Department of Paediatric Surgery, West China Hospital, Si-Chuan University, Si-Chuan 610041, China Faculty of Medicine, Nursing and Medical Sciences, Department of Paediatrics, Department of Surgery, Monash Institute of Medical Research, Monash University, VIC, Australia c Department of Ultrosonography, West China Hospital, Si-Chuan University, Si-Chuan 610041, China b
Received 20 July 2009; accepted 31 July 2009
Key words: Earthquake; Children; Disaster management; Triage; Posttraumatic stress disorder
Abstract Purpose: The study aimed to review the effect of modifying triage strategies on the consultation and operation waiting times during the Wen-Chuan earthquake in China in 2008. Method: The triage during the post-earthquake period was categorized into 3 phases. The consultation and operation waiting times were analyzed. Results: Of the 119 admitted children, there were 58 boys and 61 girls. Most of the victims were schoolaged. In phase 1 (24 hours after the quake), the triage waiting time was 78 minutes. The waiting time for pediatric subspecialty consultation was 3.5 hours. There was an additional 7.5-hour delay before operation. In phase 2 (24-72 hours after the quake), senior pediatric surgeons carried out the triage and consultation. The consultation waiting time was reduced to 31 minutes. Four rotating teams operated 24 hours a day. The waiting time for operation was reduced to 4.5 hours. In phase 3 (4-19 days after the earthquake), gas gangrene screening was implemented. The triage waiting times for closed and open injuries were 47 and 64 minutes, respectively. Operation waiting times of 4.4 and 4.8 hours were recorded for closed and open injuries, respectively. Compared to that of phase 1, the waiting times for both consultation and operation of phases 2 and 3 were significantly shortened (P b .05). Most of the (89%) of the injuries were orthopedic traumas with lower limb fracture being the most common injury. Intraabdominal and thoracic injuries were relatively uncommon. Conclusions: (1) Triage by pediatric surgeons in the reception area greatly reduced the delay of treatment and (2) the predominance of orthopedic injuries resulting from the earthquake indicates the focus of medical resource allocation in natural disasters of this type in the future. © 2009 Elsevier Inc. All rights reserved.
Presented at the 42 Annual Meeting of the Pacific Association of Pediatric Surgeons, Hong Kong, China, May 10-14, 2009. ⁎ Corresponding author. Tel.: +86 28 8038 8280. E-mail address: [email protected] (B. Xiang). 0022-3468/$ – see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2009.07.068
The unexpected earthquake on May 12, 2008, in WenChuan, Si-Chuan Province, China, greatly challenged the provincial medical system. The earthquake registered 7.9 on the Richter scale and occurred during school hours, resulting in numerous pediatric casualties. Our hospital was the only major pediatric surgical center close to the epicenter of the
2274
B. Xiang et al.
earthquake. The usual mode of triage in the Accident and Emergency Department in our hospital during this extraordinary disaster resulted in serious delay in surgical intervention. We modified our practice of triage after the initial 24 hours. We compared the key benchmarks of 3 patterns of triage adopted during the post-earthquake period.
1. Materials and methods Between May 12, the day of the earthquake, and May 31, 2008, 213 pediatric victims of the earthquake were
Fig. 1
received in our hospital. One hundred nineteen of them were admitted. Complete medical records were available for this group. The remaining 94 children were discharged after consultation and appropriate treatment, as 95% of them had moderate soft tissue injury alone. This latter group was not included in the analysis. The injuries sustained by the admitted children were categorized into (1) limb injury, spinal and pelvic fractures, (2) abdominal injuries, (3) thoracic injuries, and (4) multiple system injuries. Limb injuries were further subclassified into open or closed injuries, and compartment syndrome. Three triage protocols were implemented.
The flow charts of triage management through the 3 phases of earthquake resuscitation.
Pediatric injuries after the 2008 Wen-Chuan earthquake
2275
1.1. Phase 1: 24 hours after the earthquake (group 1) In accordance with Accident and Emergency Department protocol, pediatric earthquake victims were triaged to the Department of Pediatric Surgery. Pediatric surgical residents further triaged the victims into the appropriate surgical subspecialties.
1.2. Phase 2: 24 to 72 hours after the earthquake (group 2) Because of the dramatic increase in the number of transferred patients, the following modifications of the triage protocol were adopted: 1. To shorten the triage waiting time, the triage was carried out by senior surgeons in the accident and emergency department, instead of surgical residents. 2. To shorten the waiting time for operations, 4 operating teams were formed. Each team, consisting of a consultant and 2 residents, operated around the clock in rotations. 3. To guarantee adequate rest for the operating teams, the postoperative care was carried out by the nonoperating surgical staff.
1.3. Phase 3: days 4 to 19 after the earthquake (group 3) Additional gas gangrene screening and isolation were implemented. Wound swabs were obtained from all open wounds for gram-positive cocci screening (Fig. 1). The data were analyzed using Student t test, with P b .05 being considered statistically significant.
2. Results Of the 119 children admitted into our hospital, 83% presented 48 hours after the earthquake, well beyond the
Table 1 The characteristics of the injured children admitted in each post-quake phase Time injury Case numbers Age (after the Male Female Preschool School (mean ± SD) quake) age Within 24 h 4 Between 24 17 and 72 h After 72 h 37 Total 58
6 24
3 7
7 34
7.25 ± 4.25 9.42 ± 3.47
31 61
16 26
52 93
8.71 ± 3.53
Fig. 2 Categorization of the injuries of patients admitted throughout the different phases after the earthquake.
crucial “golden” resuscitation period. This included a 10-year-old girl who was buried for 105 hours. There were 58 boys and 61 girls with age ranging from 3 months to 14 years. There was no age difference comparing children admitted in group 1, 2, or 3. However, there were significantly more school-aged children than pre-school children in all of the groups (Table 1). Of the 119 children analyzed, bone fractures accounted for most of the injuries. This included 22% upper limb fractures, 49% lower limb fractures, 10% pelvic fractures, and 14% compartment syndrome. There were significantly more orthopedic traumas than other types of injuries (Fig. 2). Hence, fracture reduction and fasciotomies accounted for a substantial proportion of the operations performed. Wound swabs revealed gram-positive cocci in 80% of cases, but there were no positive blood cultures observed. We carried out 63 emergency operations. Details relative to injury classification and intervention are listed in Table 2. There was no mortality among the entire group of 119 children admitted to our institution. Sixty-five percent of the admitted children had from various degrees of psychological stress, manifested by fear, irritability, severe insomnia, hallucination, and compulsive behavior. In phase 1 (n = 10), the average waiting times for triage and pediatric surgical consultation were 78 minutes and 3.5 hours, respectively. The average waiting time for operation was 7.5 hours. In phase 2 (n = 41), the waiting times for pediatric surgical consultation and for operation were reduced to 31 minutes and 4.5 hours, respectively. During phase 3 (n = 68), change of garments and isolation protocol were implemented as there were 48 cases of suspected gas gangrene out of 1583 open wound patients in the adult age group (treated separately). The consultation waiting time increased to 47 minutes and operation waiting time was 4.4 hours. The waiting times for consultation and operation during phases 2 and 3 were significantly shorter than those of phase 1 (Student t test, P b .05) (Fig. 3).
2276 Table 2
B. Xiang et al. Detailed classification of injuries sustained by the pediatric population during the earthquake
Subspecialty
Injury characterization
Orthopedics
Fractures
Upper Limb
Lower Limb
Associated Nerve Injury
Limb compartment syndrome Dislocation General
Pelvic Skull Thoracic spine Brachial plexus Femoral nerve Radial nerve
Shoulder Atlas
Liver fracture Soft tissue injury Hemopneumothorax
Thoracic
Humerus radius, ulnar Clavicle Femur Tibia, fibula Calcaneus Patella
Case number
Management Operative
Nonoperative
12 13 1 23 19 16 2 12 2 4 1 4 2 17
9 10 1 21 14 3 2 1 0 0 0 1 1 17
3 3 0 2 5 13 0 11 2 4 1 3 1 0
1 1 5 4 4
1 0 3 3 3
0 1 2 1 1
3. Discussion
3.1. Earthquake trauma pattern
We have reviewed the triage and resuscitation of 119 pediatric victims of the strongest earthquake in modern China. We altered the routine triage protocol according to the patient volume load. Experienced surgeons were sent to the reception area to carry out consultation. Four operating teams worked around the clock. These extraordinary measures in the face of this extreme natural catastrophe greatly reduced the waiting times for consultations and surgical operations.
The predominance of orthopedic trauma is similar to the pattern of earthquake injuries reported in the literature throughout the world [1,2]. In the children we treated, this injury pattern was observed mainly as a result of collapsed buildings. The earthquake occurred during school hours, and most of the children were inside school buildings at the time. Most of the patients with head injuries were admitted to the neurosurgical unit. Neurosurgery department data showed that cervical fracture and closed head injuries were common. Although open skull wounds were relatively rare, it is possible that many children with this type of injury did not survive the initial trauma and, therefore, were not brought to our attention. In this regard, our data analysis may not represent the complete spectrum of earthquake injuries which occurred during this disaster.
3.2. Lessons learned
Fig. 3
The effect of triage adjustment on the waiting time.
3.2.1. Golden hours of resuscitation Change of triage practice in our institution enabled us to cope with large number of transferred trauma patients. It effectively reduced the waiting time for both consultation and operation. It may have also minimized the development of gas gangrene. Yet, review of our experience showed that, of the 1324 adult and pediatric admissions into our hospital, only 5.89% were admitted within the first 12 hours after the earthquake. The low mortality rate in our cohort of 119 pediatric patients reflects the nature of the transfer pattern. Those who were admitted into our hospital most likely
Pediatric injuries after the 2008 Wen-Chuan earthquake
2277
represented a selected group of children who survived the initial impact of the earthquake. Wen-Chuan is a mountainous area with many peaks exceeding 2500 m in altitude. Many valleys are more than 1800 m deep. The earthquake completely interrupted most of the roads and telecommunication. Many critically injured children died at the scene before transport was possible. Official government figures include 5335 school-aged children who died in the WenChuan earthquake. The extreme terrain at the epicenter and lack of adequate helicopter airlift resource prohibited the timely evacuation of most of the severely injured children during the critical first few hours after the earthquake. Employment of helicopter transportation during the second 24-hour period enabled more effective patient transport, and 22.5% of the victims were admitted during the next 2 days [3] (24-72 hours after the earthquake). These findings suggest that improved logistic preparation, mass casualty training, and surge helicopter deployment capability to facilitate more timely and volume-adequate evacuation immediately after an earthquake in the future could substantially reduce morbidity and mortality [4-6].
quiet environment. In addition, group play therapy in conjunction with a program consisting of appropriate exercise and adequate nutrition was carried out. A small group of children was unresponsive to this management protocol and some patients demonstrated a hostile attitude toward treatment. One-on-one daily consultations were instituted for those children who expressed aggressive behavior. Of the cohort with PTSD, no child displayed any signs of permanent psychological trauma on discharge. These children were followed clinically on a monthly basis for the first 6 months after discharge and at 2-month intervals after that. Most have returned to their community and restarted school. Interestingly, the overworked medical staff also displayed various degrees of depression, attention deficit, fatigue, and insomnia. We organized 3 talks for the medical staff to provide guidance and to reduce the psychological stress impact on the staff.
3.2.2. Capacity surge The sudden requirement to provide for the urgent surgical needs of so many injured children placed an unusual burden on our health delivery system. The surge of bed demand (usually capacity of 124 beds) was met by the addition of 70 beds. Some stable in-patients, admitted before the earthquake, who had adequately recovered from illness, volunteered for discharge from the hospital. Four groups (9 per group) of pediatric orthopedic and general surgeons were mobilized from the rest of the country to join the effort of Hua-Xi Hospital. Within 24 hours of the earthquake, we identified the increasing trend of delay in triage and operations. The change of triage practice and formation of the operating teams to work around the clock greatly improved the delivery of medical care. To better understand the injury characteristics and management requirements particular to this type of disaster, we have established a central data bank and have collected more than 5000 cases of pediatric earthquake victims from multiple centers in the earthquake affected area.
3.3. Psychological trauma The earthquake also traumatized the victims psychologically, especially the pediatric victims [7-10]. Among the 119-child cohort, 65% displayed significant posttraumatic stress disorder (PTSD) consisting of anxiety, fear, fear of darkness, and insomnia. Therefore, on the third day after the earthquake, the South West Psychological Health Center established a “Psychological Treatment Center” in the pediatric surgical ward. Children diagnosed with PTSD were treated by trained psychologists using a protocol that included daily specialized group counseling conducted in a
3.4. Conclusion Our experience demonstrated that adaptation of triage protocols, mobilization of additional personnel resource, and increased helicopter availability for the evacuation and transport of injured children could greatly improve the relief work involving natural disasters in the future.
References [1] Bozkurt M, Ocquder A, Turktas U, et al. The evaluation of trauma patients in Turkish Red Crescent Field Hospital following the Pakistan earthquake in 2005. Injury 2007;38:290-7. [2] Helminen M, Saarela E, Salmela J. Characterisation of patients treated at the Red Cross field hospital in Kashmir during the first three weeks of operation. Emerg Med J 2006;23:654-6. [3] Gao H-G, Qin Q, Lin D-J, et al. Triage algorithm analysis of 2621 patients 3 weeks after Wenchuan earthquake. Chin J Evid Based Med 2008;8(9):718-21 [Chinese]. [4] American Academy of Pediatrics Committee on Pediatric Emergency Medicine, American Academy of Pediatrics Committee on Medical Liability, Task Force on Terrorism. The pediatrician and disaster preparedness. Pediatrics 2006;117:560-5. [5] Olympia RP, Wan E, Avner JR. The preparedness of schools to respond to emergencies in children: a national survey of school nurses. Pediatrics 2005;116:e738-45. [6] Cicero MX, Baum CR. Pediatric disaster preparedness: best planning for the worst-case scenario. Pediatr Emerg Care 2008;24:478-81 [quiz 482-4]. [7] Williams R, Alexander DA, Bolsover D, et al. Children, resilience and disasters: recent evidence that should influence a model of psychosocial care. Curr Opin Psychiatry 2008;21:338-44. [8] Jones L. Responding to the needs of children in crisis. Int Rev Psychiatry 2008;20:291-303. [9] Betancourt TS, Khan KT. The mental health of children affected by armed conflict: protective processes and pathways to resilience. Int Rev Psychiatry 2008;20:317-28. [10] Chandra V, Pandav R, Bhugra D. Mental health and psychosocial support after the tsunami: observations across affected nations. Int Rev Psychiatry 2006;18:205-11.