The Dragon Strikes: Lessons from the Wenchuan Earthquake

To know the road ahead, ask those coming back. –Chinese Proverb The devastation caused by the earthquake striking Sichuan Province in southwestern China in 2008, interchangeably referred to as the Wenchuan earthquake or the Sichuan earthquake, posed a severe challenge to anesthesiologists and other medical and rescue personnel. They were faced with the nightmarish task of providing relief to thousands of injured victims, many trapped in isolated areas cut off from timely assistance by impassable roads, disabled communication networks, bad weather, and the sheer number of casualties. Because of our longstanding relationship with Chinese anesthesiologists, the Editor-in-Chief of Anesthesia (2) collecting anatomical data and identifying “significant injuries” (e. g. , multiple long-bone fractures) ; and (3) assessing the mechanism of injury. The authors reported that “by the second and third steps. . . we triaged approximately 20% of patients as urgent, having only 34 min elapsed. ” The greatest threat to efficiency in evaluating patients often came from the “walking wounded, ” victims not in immediate need of critical care and comprising the majority of casualties presenting to West China Hospital. These people (849 patients) were often the first to arrive at the hospital asking for help. They added to the already confused situation by crowding into the hospital's emergency department, interfering with patient evaluation times, and delaying treatment for the critically injured. The authors emphasized that “in a disaster medical triage system, it is not only very important to give treatment to the most critically ill, but also to triage the walking wounded out of the emergency department” (Supplement 4). Be Prepared to Treat Injuries Common to Earthquake Victims Most patients admitted to West China Hospital had fractures. Many had to undergo amputations. Orthopedic, craniocerebral, thoracic, and abdominal injuries were common. At West China Hospital, unlike the situation in the field where regional anesthesia was the rule, most of the 875 surgical procedures were performed using general anesthesia (70. 5%) (Supplement 5, see Supplemental Digital Content 5, https: //links. lww. com/AA/A69). As more time elapsed, and the time pressure decreased, the use of regional anesthesia (e. g. , brachial plexus block, spinal anesthesia, and epidural anesthesia) increased. Many quake victims had injuries and complications directly related to the treatment delay imposed by the widespread and massive destruction of the transportation infrastructure. Dehydration and electrolytic disturbances were common. Crush syndrome, accompanied by gas gangrene and renal failure, was a common complication in patients who had been buried under rubble for a long time before being rescued (Fig. 8). The inordinate number of gas gangrene cases called for special attention. These patients became so numerous that West China Hospital physicians introduced specific testing (serum potassium and wound smear Gram stain/culture) for gas gangrene and crush syndrome into their triage algorithm to identify and assist these victims quickly (see Supplemental Digital Content 4, https: //links. lww. com/AA/A68, and Supplemental Digital Content 6, https: //links. lww. com/AA/A70). Figure 8.: Man caught under rubble (available at: http: //hailin. files. wordpress. com/2008/05/manᵤnderₑarthquake. jpg). Hospital physicians soon noticed an unexpected iatrogenic complication caused by well-intentioned butuntrained rescuers. As described by one source, “some victims managed to survive many days under fallen structures and debris, only to suffer a dramatic death when their limbs were rapidly released without proper fluid administration” (Fig. 9) (Supplement 6, see Supplemental Digital Content 6, https: //links. lww. com/AA/A70). In their zeal to rescue trapped victims, untrained rescuers failed to protect victims from the sudden revascularization of a limb after prolonged ischemia, with devastating results. Figure 9.: Woman rescued after being trapped for 50 hours under debris (available at: http: //www. aems. uiuc. edu/images/800px-Sichuanₑarthquakeₛave. jpg). Provide Pain Management In the aftermath of the quake, researchers from West China Hospital sought to determine how effectively the victims' pain had been treated and sent trained interviewers to 7 towns near the epicenter to conduct face-to-face interviews with quake-injured patients (Supplement 7, see Supplemental Digital Content 7, https: //links. lww. com/AA/A71). In all, 848 victims were questioned about the treatment of their pain before and after they reached the hospitals and during the postoperative period. The results were disturbing. Although these victims experienced severe pain from their injuries, very few received any pain treatment at all after the quake. The treatment they did receive was often inadequate, even after they had been transferred to the hospital. The researchers described as “astonishing” the degree to which pain was neglected in field emergency areas and characterized the underrecognition and undertreatment in general as “hard to comprehend. ” Did rescuers assume that victims would ignore their pain because all their attention would be focused on the injury itself and on the possibility of losing their lives? Were pain medications simply unavailable? The researchers were unable to find a clear explanation, and the causes are probably multifactorial. The undertreatment of pain, however, is a matter of concern and controversy worldwide and is common enough that a specific is to describe it (Table 1, No. 3). It is that the magnitude of the disaster and the sheer number of victims in pain simply and of the this study the need for greater that for pain after are in for and of the most aspects of was the and with which thousands of people were to work in the rescue and relief after the earthquake, the Chinese thousands of into the Sichuan province. As soon as to the of the quake zone and into the areas to conduct rescue repair roads, and In to hundreds of Chinese the opened its to medical personnel and rescue experts (Table 1, No. 4). Within a few medical had around Sichuan. These set up field hospitals and care and The first regional team arriving at West China Hospital, as one author presented a significant challenge to the numbers of people from of and with of equipment posed a challenge of effectively under such (Supplement 3). the challenge was and by the time these medical left they had treated some patients and performed They also by clinical and and by people (Supplement see Supplemental Digital Content Dr. from the at the of a in critical care and out at West China Hospital for several weeks after the quake. the Chinese to the disaster as very and and that having the to work with Chinese physicians in the emergency department was MD, communication, June Dr. who up the group, called their experience of us for the of our (Table 1, No. of The medical to a major earthquake timely and and of drugs and care in rescue and relief efforts be trained in emergency care and be by of other emergency personnel. must be to that medical personnel work in a safe so that they provide care for the casualties rather than casualties In to the lessons in this many more could be for personnel with victims on rather than in hospital. These would for in regional anesthesia and for providing assistance in resources are or The of victims of crush injuries found after hours or days with limbs must also be resources the earthquake and aspects of the are in on the THE THE DRAGON The damage caused by this earthquake was so and widespread that the road to for Sichuan Province be long and infrastructure damage has been estimated at of No. 6). and for this work has been Although millions of people are still in the Red that because of of most be into by the of this (Table 1, No. The medical has the work of West China Hospital is the lessons learned during the quake into for earthquake have been and training are for staff anesthesiologists and those from the earthquake's epicenter zone (Yunxia Zuo, MD, PhD, e-mail communication, June 4, 2009). The hospital has a it with hospitals in the region. This has already and treatment for patients (Table 1, No. 8). Most West China Hospital and staff have that the emphasis during the of their medical relief work must be on and This no an that although and hospitals be building and displaced many left by the quake are not as as collapsed As of this several including the Red have the death at greater than estimated (Table 1, No. Although numbers are not available and are there is that many hundreds of these casualties were (Table 1, No. The death of so many throughout the have significant that be to and to The of such a disaster and their long-term although to than damage to the are a The of Anesthesia & Analgesia the of our colleagues in China. to provide multiple of their after the Sichuan earthquake has our their to this article. the greater is the their patients. to patient and their and in the most of make us to be the of Anesthesiology, West China Hospital, Sichuan of Anesthesiology of Daping Hospital, of Medical of Anesthesiology, Hospital of Sichuan Medical of Anesthesiology and Pain The of Medical at Chinese West China Hospital, Sichuan of Emergency West China Hospital, Sichuan of Pain and Operating United Hospital, of Emergency Hospital, Hospital, and of Department of Anesthesiology, of in by a from the Chinese Medical from the of and general from the Medical of Sichuan the Department of Anesthesiology of the West China Hospital of Sichuan and the of of Sichuan