The Hindu Business Line : Management of mass casualties

DAZED by the Delhi blasts and wincing at the visuals of victims wheeled into hospitals, you'd agree that coping with `mass casualties' has become necessary owing to the rising incidence of violence.

"The use of sophisticated weapons and explosives by terrorists and other antisocial elements has led to injuries hitherto seen only in warfare or during military manoeuvres," notes an article in Journal of Postgraduate Medicine (www.jpgmonline.com) titled `Analytical data of March 1993 blast victims - the KEM Hospital experience,' by Shenoy SG, Pai PR, Dalvie S, Bapat RD, of KEM's Department of General Surgery. The Delhi one is a parallel, though of a different scale, because on March 12, 1993, Mumbai experienced about a dozen explosions in different places including the stock exchange, where "at 1:30 pm a powerful car bomb exploded in the basement," as Wikipedia chronicles.

"A total of 248 casualties (excluding 79 brought in dead on arrival), were received at the KEM hospital within 5 hours from 14.30 hrs to 19.30 hrs. The majority of casualties arrived in 2 waves of 20 minutes each with an interval of 30 minutes in between," narrate the doctors. "The first wave brought about 200 victims from the Worli blast and the second 48 victims from the Dadar blast."

What injuries happen when an explosive device is detonated? "Primary injury is caused by the blast wave alone as a result of the interaction between the human body and the set up stress, shock and shear waves," describes the paper. "Secondary injuries are caused by the bomb casing and other secondary missiles, which result in blunt or penetrating injuries." Plus, there are `tertiary injuries' caused by the blast wind, to result in `traumatic amputations or head injuries'; and burns from flames, and crush injuries caused by falling masonry.

In general, destiny is a matter of distance when it comes to blast. The first zone nearest the blast may have an overpressure in excess of 550 kPa (short for kilopascal, a measure of force, equal to 10 millibars, 0.2953 inches of mercury, or 0.145 pounds per square inch) leaving no survivors, and death may be due to severe primary lung injury, explain the doctors. "Air filled organs like the ear, lungs and gas filled bowel are maximally damaged by the blast wave," informs the paper. "All patients with evidence of tympanic membrane rupture must be closely observed for signs of lung damage, which may manifest after 24 hours," it instructs.

Let me not go into the gruesome details of major surgeries performed, which may merit a separate discussion, but instead look at a few of the lessons that the doctors highlight. One, supplementing of the quickly `saturated' space in the `usual receiving area of the hospital'; two, using `all medical personnel available in the hospital at that time' including interns and students; three, regrouping of `surgical units'; four, very important, triaging of casualties `into serious, expectant and minimal categories' for `optimal utilisation of scarce hospital resources'; five, `a news bulletin renewed every hour' announced over a public address system and displayed in a prominent place; and six, separate holding areas `for identification, and documentation of the large number of bodies brought dead on arrival'.

The paper concedes the need for maintaining `ready-made proformas and a uniform system of wound classification', and using `plastic or metal bracelets with temporary registration numbers' for patients. "This experience once again demonstrated the need for an improved integrated disaster protocol for the institution," conclude the authors. Are you ready enough in your institution?

E&OE@TheHindu.co.in

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