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Review of Anesthesia Team Response: Rescue Effort from the Largest Hospital near Wenchuan
Earthquake Epicenter
Authors:
Tao Zhu, M.D,1 Rong-Mei Li,2 Wen-Xia Huang,3 Zhen-Hai Yao, PH.D, M.D, 4 Jin Liu, M.D.5
1. Tao Zhu, Professor, Department of Anesthesiology, West China Hospital, Sichuan
University, Chengdu, Sichuan 610041, China
2. Rong-Mei Li, Administration Assistant, Hospital , West China Hospital, Sichuan
University, Chengdu, Sichuan 610041, China
3. Wen-Xia Huang, Chief Nurse of Operating Room, West China Hospital, Sichuan
University, Chengdu, Sichuan 610041, China
4. Zhen-Hai Yao, Professor, Department of Anesthesia and Pain Management, Toronto
General Hospital, 3 Eaton North 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada
5. Professor and Chairman of Department of Anesthesiology, West China Hospital, Sichuan
University, Chengdu, Sichuan 610041, China
Corresponding Author
Jin Liu, MD
Professor and Chairman
Department of Anesthesiology,
West China Hospital,
Sichuan University,
Chengdu, Sichuan 610041, China,
Tel: +86-28-85422520
Fax: +86-28-85423591
E-mail: xwtao_zhu@yahoo.com
Short title: Anesthesia team in Wenchuan earthquake
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Background: On May 12, 2008, an earthquake with a magnitude of 8.0 on the Richter scale
occurred in southwest China’s Sichuan Province. We examined the emergency management
strategies used by the anesthesia team of West China Hospital. The experience of our anesthesia
team may have implications for operating room emergency management in responding to any
major disaster.
Methods: We reviewed the activities of the anesthesia team of our hospital between May 12 and
June 11, 2008 after the Wenchuan earthquake. The analysis was based on the data provided by
the hospital’s Department of Information.
Results: Within 3 hours of the earthquake, a rescue team comprising 5 anesthesiologists and 5
nurses set out for the disaster area. As of July 11, 1,265 operations for earthquake injuries had
been performed, in operating rooms (ORs). Most surgeries during the initial peak of surgery
(May 14) were for amputations (43%). Most patients in the second peak (May 23) received
second-stage procedures such as open reduction and internal fixations (61%). During this rescue,
61 (7.0%) surgeries for suspected gas gangrene were performed. Five regional surgical teams
helped in our hospital for 12 days and participated in 585 procedures.
Conclusions: The Wenchuan earthquake was the worst disaster in China in the past century.
Quick response and OR efficiency are the keys for delivering quality medical service to a large
number of earthquake trauma victims during such a short period of time. Emergency
management of the OR can be accomplished effectively and safely with the use of available
resources and personnel.
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On May 12, 2008, an earthquake measuring 8.0 on the Richter scale struck southwest China’s
Sichuan Province. The epicenter was in Wenchuan County. The death toll as of September 22,
2008 was 68,712 with 374,643 injuries.*
West China Hospital, the largest hospital near the epicenter, has a capacity of 4,300 beds with 62
operating rooms (ORs). There are 55 attending doctors and over 150 residents in the Department
of Anesthesiology. For the year of 2007, over 50,000 procedures were performed in ORs and
20,000 general anesthetics were delivered outside the OR.
West China Hospital played a crucial role in providing emergency disaster relief between May
12 and June 11, 2008. Over the course of 30 (sleepless!) days, West China Hospital received
2,695 injured patients, of which 1,825 were hospitalized, and performed 1,265 operations. In this
article, we describe how our anesthesia team functioned in response to the sudden influx of a
large number of trauma victims.
Initial Assessment
When the earthquake struck there were 55 ongoing operations in our ORs: 45 under general
anesthesia and 10 under local anesthesia. During both the initial earthquake and the many strong
aftershocks some anesthesia machines and monitors fell to the floor. The first few minutes were
chaotic. In this situation, patient safety was paramount in our minds. Immediately, patients in the
holding area and postanesthesia care unit were relocated to safer areas.
*
http://en.wikipedia.org/wiki/2008_Sichuan_earthquake, last accessed October 5, 2009
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Thirty-seven of the ongoing operations were quickly ended. We decided to continue the
remaining 18 operations because there was not a safe way to quickly end the surgery. On the day
of the earthquake, we managed to complete 133 elective surgeries by 5:05 pm. Although we
applaud our dedicated staff (nursing, anesthesia, surgery, and support personnel), we point out
that continuing work in the presence of powerful aftershocks represents a personal risk to staff
and patients. In general, all elective cases not already underway should be cancelled after such a
disaster.
West China Hospital Rescue Team
Simultaneously, we organized a rescue team in our hospital. Within 3 hours of the initial quake a
rescue team comprising 5 anesthesiologists (1 attending anesthesiologist and 4 residents) and 5
nurses set out for the disaster area. Arriving at the scene, we found local hospitals demolished
and thousands of victims crushed to death. Many more were trapped inside collapsed buildings
desperately awaiting rescue. The rescue efforts were complicated by numerous aftershocks and
bad weather. We brought bandages, simple external fixators, lighting, warming equipment, local
anesthetics, analgesics, sedatives, and numerous appliances for debridement, amputation, and
neurosurgery to the disaster area. The medical rescue team of our hospital treated 850 injuries,
including 410 fractures in the field.
On-site rescue efforts were reviewed after the event. Anesthesiologists played a critical role
during the first two weeks after the quake. Anesthesiologists in the first wave of rescue teams
realized that they had not brought enough emergency equipment for endotracheal intubation and
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first-aid. After two weeks, when most injuries had been transferred to and treated in nearby
undamaged hospitals, the primary task in the disaster area was to focus on primary health care.
Preparation for Victims Arriving From the Disaster Area.
No anesthesia or nursing personnel at the West China Hospital were injured. All members of the
anesthesia team (anesthesiologists and nurses) were urged to (1) remain in Chengdu, (2) make
themselves reachable via pager, home phone, or cell phone, (3) arrive in the ORs within 30
minutes of being paged. We divided our members into 5 groups. Each group consisted of 6-7
attending physicians and 18-20 residents working in 12-hour shifts. Nurses were divided into 3
groups of 25, working in 8-hour shifts. Two senior professors (1 surgery and 1 anesthesia) were
responsible for triage during the first 24 hours.
Operating Rooms
Sixty two ORs in our hospital were located on 5 different floors. This distribution of facilitates
allowed for isolation and quarantine of patients with potential infections. After the earthquake we
selectively isolated each floor for sterilization or for patients with potentially serious infections
by equipping each floor with independent entrances and exits. In this way, we maximized the use
of all 62 ORs. During the initial 3 days (May 12 to May 14) of rescue, 11 ORs performed 36
procedures each day. To accommodate all victims arriving at our hospital during this emergency,
the daily need for ORs varied between 11 and 20.
At all times, one or two ORs with separate transport entrances and exits and independent laminar
flow and air purifying systems were set up for emergency surgery on infected patients. In our
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hospital, a maximum of 5 ORs can be available for such surgery. Therefore, this design and
distribution of ORs reduced and prevented the cross infection of gas gangrene and drug-resistant
bacteria between victims.
Rescue of Earthquake Trauma
The Chinese government’s rescue response was quick, effective and well organized. Earthquake
victims were initially transferred out of the epicenter via helicopters. After 2 days of struggle, the
Chinese army restored earthquake-damaged roads to the epicenter, which resulted in the
effective transportation of a large number of trauma victims and the initial peak of hospital
admissions. Our hospital and Chengdu city’s emergency medical center created a triage center at
the army base airport. Victims from the Wenchuan epicenter were quickly disseminated to
various hospitals. Our hospital received additional victims from many other quake-shattered
areas including Shifang, Deyang, Du Jiangyan and Mianyan.
The first victim of the Wenchuan earthquake arrived at our hospital at 15:40 on May 12. Over
the following 30 days, 2,695 victims from the disaster area were treated in our hospital (1,825
inpatient; 1,265 procedures). Hospital admissions peaked 2 days after the earthquake on May
14th at 220 cases. Admission diagnoses were fractures (55%), craniocerebral injuries (10.0%),
and thoracoabdominal injuries (7.5%) (Table 1). There were 875 procedures performed in our
ORs. The most common operation was amputation (Table 2). Admissions and surgery associated
with the earthquake between May 12 and June 11 are presented in Figure 1.
The second peak of hospitalization occurred on May 20, 8 days after the earthquake (200 cases).
Since our hospital is the largest medical center in Western China, from this day a significant
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number of seriously injured victims were sent to our hospital directly from the airport after
receiving urgent treatment in the disaster area. In addition, many critically injured patients were
further triaged to us from nearby emergency facilities in Deyang and Du Jiangyan and from other
hospitals in Chengdu. The majority of these victims suffered from complicated orthopedic
injuries and required second stage open reduction and internal fixation procedures (61%) (Table
2).
Management of Gas Gangrene
To prevent cross infection of gas gangrene and drug-resistant bacteria among the injured, a
standard protocol (wound examination flow chart) was created and strictly enforced (Figure 2).
Prior to entering the emergency department, all patients were changed into isolation gowns.
Secretion smears, aerobic and anaerobic cultures, as well as tests for drug sensitivity, were
performed on all admissions with open wounds. Results of these tests dictated where patients
would be sent (isolation ward or infected OR for surgical procedures). Two days after the
earthquake, patients with suspected gas gangrene and drug-resistant bacteria infections increased
markedly. Up to June 11, 67 cases of suspected gas gangrene among the earthquake victims were
identified, 32 (47.8%) of whom were strongly suspected of having gas gangrene infection. The
isolated and designated OR was set up and a specialized surgical team prepared to take care of
these patients. During this rescue, 61(7.0%) such procedures were performed in our ORs.
Effective use of multiple surgical teams from other parts of China
In response to a disaster of such magnitude, Chinese and international volunteers poured into our
hospital to provide assistance. To avoid chaos and effectively use this volunteer resource, the
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Chinese central government selected and organized 5 regional surgical teams (25 different
hospitals from Beijing, Tianjin, Jilin, Harbin and Hong Kong), which included 50 orthopedic
surgeons, 17 anesthesiologists, and 35 OR nurses. The first regional team arrived at our hospital
on May 15. Huge numbers of people from various backgrounds, different styles of practice, and
varying familiarity with different varieties of equipment posed a difficult challenge for effective
cooperation under such stressful circumstances.
There is no doubt that these 5 regional surgical teams made a prompt and huge contribution to
relief task forces in our ORs. Our staff members were effective in organizing and coordinating
these enthusiastic colleagues to maximize the effectiveness of the operation. To cope with the
inevitable chaos during the first few days of rescue, we developed a plan for establishing an
emergency command, execution, and coordination of systems in an effort to maximize patient
safety and provide an orderly rescue. One staff anesthesiologist from each rescue team was
responsible for one OR. One nurse from the rescue team was responsible for scrubbing or
circulating to assist the in-charge staff nurse. One staff anesthesiologist and one in-charge nurse
from our hospital served as the principal coordinators and commanders-in-chief of the system in
the OR.
Patient safety was paramount in this chaotic environment. A daily procedure list including names
of patients and surgeons was posted at each OR’s entrance. We enforced the use of the
mandatory time-out by surgeons, anesthesiologists, and nurses to ensure that the planned surgical
procedures were performed on the correct patients by qualified surgeons. Regional help teams
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stayed in our hospital for 12 days and participated in 585 procedures, of which 188 (32.1%) were
completed by them independently.
Procedures of Earthquake Related Patients and Non-earthquake Related Patients
Western China Hospital is the largest and most advanced diagnostic and treatment center in
China and a major part of the regional health care network that covers nearly half of all China.
Since the Wenchuan earthquake struck on May 12, our outpatient division has remained
continuously open and continues to care for its routine patients, some of whom were waiting for
admission and elective surgery.
However, all elective surgery was put on hold, which produced a backlog of patients over time.
On May 12 the day of the earthquake, 57 of 190 elective operations were cancelled. The next day
on May 13, 187 scheduled procedures were cancelled to accommodate the patients from the
earthquake. Most of these patients were from outside Chengdu, but chose to wait in the hospital.
Consequently, the list of elective, non-earthquake related cases was growing and becoming an
urgent problem. Although rescue was the number one priority, the whole anesthesia team and
hospital staff worked extremely hard to accommodate as many patients as possible. We
maximized the use of all 62 ORs in the 30 days after the initial strike of the Wenchuan
earthquake. A total of 3,471 cases were treated in our 62 ORs, 2,596 of these (74.8%) were
elective procedures not related to the earthquake. Compared to the elective procedures performed
in May 2007 (3,377), this is a 2.8% increase.
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Conclusion
The Wenchuan earthquake was the worst natural disaster in China in the past century. This was
the first time that our hospital played the key role in the rescue effort after such a massive natural
disaster. The prompt and effective response of the anesthesia team at West China Hospital
contributed to the saving of countless lives and can serve to guide other hospitals when dealing
with large scale natural disasters.
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Figure legends.
Figure 1 Chart for Admission and Performed Procedures (May12 to June 11)
Figure 2: Triage Flow Chart
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Table 1: Admission diagnoses after the Wenchuan earthquake
Admission diagnosis
Fracture
Craniocerebral injury
Thoracoabdominal injury
Compartment syndrome
Crush syndrome
Ocular injury
Others
Number of patients
1018
182
140
20
17
6
442
Percent
55.8%
10.0%
7.7%
1.1%
0.9%
0.3%
24.2%
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Table 2: Surgical procedures during the two patient peaks after the Wenchuan earthquake
Surgical Procedure
Amputation
Debridement and suturing
Open reductin and internal fixation
(ORIF)
Other
Initial Peak Second Peak
(%)
(%)
43%
4%
22%
21%
15%
20%
61%
15%
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Figure 1:
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Figure 2: