Trauma response to the Asian tsunami: Krabi Hospital, Southern Thailand

Abstract

The date 26 December 2004 saw a massive tidal wave propagated from a 9.0 Richter scale suboceanic earthquake off the coast of Sumatra in South-East Asia. It swept across the Indian Ocean over a matter of hours leaving destruction in its wake. In Southern Thailand, Krabi Hospital, that province's major tertiary health centre, received the majority of the region's tsunami victims. Well-rehearsed contingency plans were in place to cope with 10, 20 and 40 trauma victims in the case of an extreme event. By the end of 26 December some 500 injured people had been treated at Krabi Hospital: well in excess of the ‘worst case scenario’ planning. Over the following days a total of 1357 tsunami victims were treated. Over the course of the day victims were able to move through the hospitals’ system and gain appropriate treatment. This was achieved through the almost superhuman dedication of the hospitals’ well-trained nursing and medical staff. In addition to this were large numbers of both Thai and foreign volunteers, who aided people with basic necessities such as providing them with food, water and clothing as well as simple human comfort, some also acting as translators for the health-care workers and the masses of injured and displaced people. Makeshift wards were constructed in halls and little used areas of the hospital, using army style stretchers to accommodate the wounded. Even though the disaster contingency plans at Krabi Hospital were utterly overrun, the fact that well-thought out and practised strategies were in place saved incalculable lives. The message is clear: practised responses to mass trauma situations will save lives and allows health-care teams to coordinate well in the face of overwhelming odds without panic. All centres should routinely practise disaster response through scenario-based training.

Introduction

The morning of 26 December 2004 will stay in the minds of most people as the day that the earth felt the effects of a 9.0 Richter scale suboceanic megathrust earthquake that generated a massive tsunami, the likes of which had not been recorded in the region ever before. A gigantic wall of water swept across the Indian Ocean changing human lives in an event of such natural ferocity that those of us who lived through it will have the memories for all time.

In Krabi Province, Southern Thailand, the calm and bright morning was shockingly altered and in a matter of minutes, people were dying, crying and standing in silent disbelief while staring out to sea as the waters from the three main waves of the tsunami disjointedly subsided. It was unquestionable that widespread trauma had been inflicted in the area – how was the health system going to deal with this event?

On 28 March, nearly 3 months later to the day, just as the situation seemed to be returning to normal operational conditions, another massive quake occurred: again off the coast of Sumatra, 107 km north-west of Nias island. The 8.7 magnitude quake killed around 1300 people and prompted evacuation alerts in Thailand and other previously tsunami-affected countries as fears of history repeating itself were a very real concern. Previous strategies that were used on 26 December were put into action immediately.

How the day and week unfolded

At approximately 09.00 hours the Krabi Hospital received reports of an earthquake off the coast of Sumatra in Indonesia – several thousand kilometres to the south – that had occurred at around 07.00 hours. The tsunami that it birthed swept through the Andaman Sea at around 10.45 hours, battering the coast and islands that are a haven for holiday makers the world over, but particularly Europeans escaping the cold winter in what was peak tourist season for the region.

By 12.00 hours casualties were being treated at the Krabi Hospital – evacuated from the local areas of Ao Nang, Koh Poda, Railay Beach, Koh Lanta and Koh Phi Phi. The 330-bed hospital was running at around 90% occupancy (Krabi Hospital, unpubl. data). People were being triaged in the field by the local doctors who were available, and also by foreign doctors holidaying in the in the areas affected. In our area of Ao Nang, the local general practitioner put an ambulance and its crew (one driver, one nurse and one paramedic) at our disposal and we began triaging and treating patients at an intact jetty some 50 km away from Krabi Hospital, where boatloads of injured people were arriving off an unpredictable sea.

Patients were further triaged at the entrance to the Krabi Hospital ED by senior nursing, medical and surgical specialists into two broad categories: those with trauma that required immediate senior surgical intervention and those that sustained less severe surgical trauma and more manageable injuries. The ED was also divided into two areas to deal with this system. Within the two groups further triage according to established advanced trauma and life support principles occurred using a coloured tagging system for easy identification of case severity/urgency. Makeshift wards and treatment areas were constructed in halls, waiting rooms and little used areas of the hospital, using army style stretchers to accommodate the wounded, just to cope with the volume of injured people.

Krabi Hospital, like most large regional trauma centres, has several well-rehearsed contingency plans in place in the case of an extreme event. The plans took into account the arrival of 10, 20 or 40 trauma victims at once to the hospital. By evening of that day approximately 498 casualties had been seen at the hospital, with more arriving by helicopter and boat from the outlying islands well into the night (Krabi Hospital, unpubl. data). By the end of the first day the ‘worst case scenario’ plan had been overwhelmed in excess of 10 times the maximum ‘planned for’ casualties. The injured kept on arriving via ambulance, car, truck, helicopter, boat, scooter and foot. On Monday the 27 December another 564 casualties arrived and the Tuesday saw a further 295 (Krabi Hospital, unpubl. data). In less than 1 week the hospital treated 1357 trauma victims of the tsunami: 713 Thai people and 644 foreigners, mostly tourists, from 43 nations (Krabi Hospital, unpubl. data). World Health Organization figures state that in Thailand, 5395 people are confirmed dead, 2998 are missing and 8457 have been injured.¹ No contingency could be in place for an event of such overwhelming ferocity.

Even though the numbers of injured were overwhelming, the patients still moved through the hospital system with remarkable smoothness, receiving appropriate radiological and other investigations as were available, as well as often definitive treatment of their injuries. This was achieved through the almost superhuman dedication of the hospital's well-trained nursing and medical staff. In addition to this were large numbers of both Thai and foreign volunteers, who aided people with basic necessities such as providing them with food, water and clothing as well as simple human comfort. Many travellers who were multilingual made signs that they hung around their necks so that they could act as translators for the health-care workers and the mass of injured and displaced people. The hospital did not stop at all in its activity, although the workload did ebb and rise over time.

A total of 302 casualties required admission to the hospital and in just 6 days the surgical team (2 orthopaedists, 2 general surgeons, 2 ear, nose and throat surgeons, 4 obstetrician and gynaecologists and 1 anaesthetist) performed 149 procedures on 135 patients (Krabi Hospital, unpubl. data). Severely injured and unstable patients were treated as close to immediately as possible at Krabi Hospital as they arrived, but the surgical services were soon saturated on the first day. Patients who were stable, but required urgent (as opposed to emergent) surgical care were evacuated to the next provincial hospital by ambulance, if possible, or by any other appropriate means when this could not happen.

28 March 2005

Nearly 3 months to the day after the Boxing Day event, another large earthquake occurred 107 km north-west of Nias Island off the coast of Sumatra: near the region of the original epicentre. The 8.7 magnitude quake killed around 1300 people on Nias and prompted evacuation alerts in Thailand and other previously tsunami-affected countries as fears of history repeating itself were a very real concern. A disaster response strategy based on the experience of the 26 December tragedy was put into action at Krabi Hospital, with all medical, nursing and ancillary staff put on high alert and recalled to the hospital (N. Popattanachai, pers. comm.). Local emergency services personnel (made up largely of volunteers) were also put on alert and coordinated plans for casualty retrieval were in place. Fresh water and food supplies were appropriated for the hospital.

This situation of readiness was maintained for approximately 6 h after the initial alert of the quake's occurrence, after which time staff were allowed to step down, but still remained on immediate recall. On 26 December the tsunami generated by the 9.0 earthquake took just under 4 h to reach this region of Southern Thailand, and as no wave had been reported following the quake of 28 March, the situation was downgraded after 6 h. Thankfully, no wave eventuated and staff returned to normal operating conditions after 24 h.

Conclusions

The disaster of the Asian tsunami gave rise to a situation where trauma contingency planning became seemingly academic. Even though the trauma response plans at Krabi Hospital in Southern Thailand were utterly overrun in the wake of the wave, the fact that well-thought out and practised strategies were in place saved incalculable lives. The message is clear: practised responses to mass trauma situations will save lives and allows health-care teams to coordinate well in the face of even overwhelming odds, without panic.

The strength of trauma response that a centre can offer is not necessarily measured by the equipment and resources that the institution has (although these things obviously help) but in the manner in which it meets a challenge. Training all necessary hospital staff in disaster management is crucial if coordinated and meaningful health care is to be provided in the mass casualty situation. Education and preparedness are the keys and all centres should routinely practise disaster response through scenario-based training.

Dedication

To the staff of Krabi Hospital and their legion of volunteers: you are Heroes one and all.

Competing interests

There are no competing interests in regards to the present paper's content.