|Friday, 02 March 2012|
To mark the first anniversary of the devastating earthquake in Christchurch, Jane Bone, Clinical Director at Christchurch Hospital, recounts the events of 22 February 2011
Home from teaching and a four hour shift in the emergency departent. I look around my apartment on the eighth floor in the CBD – it’s late summer, the sun is shining, it’s warm and the 360 degree views over the city, mountains and Hagley Park are spectacular. Oh how lucky I am. Time for lunch; I nonchalantly walk into the kitchen.
The clock ticks over, a nano second of time later and the smooth rhythm of life abruptly changes – threatened and violated. The floor is thrown upwards at multiple angles, cans and homemade preserves missile out of the cupboards, the large fridge-freezer (full of fresh fruit and smoked meat) is launched into the air towards me – the roar of the quake is deafening.
Another nano second goes by … I am on the couch (a reflex dive I presume and one that has saved my life). Great fissures appear in the walls and all objects are tossed around the apartment as the quake continues its path of destruction. After what feels like an eternity it stops – for now. Bizarrely, my cell phone is still in my hand – I speed dial my sister in the North Island: “Massive, massive earthquake here, tell mum & the others I’m ok (I am one of six kids). I need to get to work – they will need us. Find Dave, Suze and the kids (my immediate family living in Christchurch – it will be six hours before I know they are ok). I’ll ring when I can.” I grab my work bag, cell charger and head lamp (have no idea where those sane thoughts came from!) and run.
The first confirmation we had was one of our senior registrars sprinting into the department to warn everyone of the carnage in town. He had been on his way home through town when the EQ hit. Fighting the huge moral dilemma of ‘stay and help or run and alert the hospital?’ – he chose the latter. We activated our disaster plan and proceeded to organise the department.
“Patients came by all modes of transport: some walked, some cycled, others were carried – they were on the tops of doors or on slabs of broken concrete, on the decks of trucks and utes, and strapped to the roofs of police cars”
Yes we train in disaster management and a couple of dry runs post September and December earthquakes have helped to hone the disaster plan. That plan helps to provide the backbone of your response and that stood us in very good stead for 22 February 2011. The plan, a whole lot of improvisation during the event and everyone working together were the key ingredients to our performance.
Patients started arriving within minutes as our hospital sits right on the edge of the CBD. They came by all modes of transport: some walked, some cycled, others were carried – they were on the tops of doors or on slabs of broken concrete, on the decks of trucks and utes, and strapped to the roofs of police cars.
As well as patients flooding to the ED so did staff – this was one of the hardest aspects to manage – everyone wanted to help and allocation of appropriate work to the 200-plus staff that sifted in was tricky. We used the Tannoy system to announce plans, give direction and keep everyone on the same page. The use of the Tannoy happened randomly but was such a success that it is now incorporated into the overall plan.
We set up trauma teams for each of the 10 resuscitation and 10 monitored bays. These teams of two doctors and two nurses were responsible for cycles of receiving and managing a patient, stabilising them, sending them to safe disposition, restocking their own room, and signaling when ready to cycle again. Specialist in-patient teams were cohorted into the central area and called for over the Tannoy to consult a patient when required, e.g. “neurosurgeon to R6, orthopaedic surgeon to trauma room.” By doing this we ensured that staff worked mostly within their field of expertise. This enabled them to function well and maximise the benefits to the patients.
Triage was done outside in the ambulance bay by senior staff. Only the most severely injured came into the ED – others were treated outside by other staff wanting to help. This took a big load off the department.
Lifts were out of action for most of the night, which meant no access to theatre, ICU, CT or DSA. Imaging was via our one portable XR machine (running on battery and unable to charge whilst in use!) and our two portable ultrasound machines. The Head Sonographer arrived down the back stairs with four more US machines and six sonographers. We used them for all the imaging of FAST scanning, myocardial assessment, vascular access, pneumo/haemothorax and even limb fracture. CT only became available later in the evening. Two radiologists camped in the ED and gave us immediate expert reading of the images.
Laboratory services continued although results came via phone, not computer. We had an I-stat in the ED which enabled point-of-care testing. The blood bank quickly had its stores of O-ve blood threatened. We limited this drain by only giving O-ve blood to severely injured female patients of child bearing age and boosted stocks by staff donating their own blood.
All requests for imaging, lab, disposition, consults came through the central point in the ED. A couple of ED physicians kept a hands-off role and did frequent circuits of the ED to ‘keep the big picture’. We prioritised all requests and co-ordinated them via the Tannoy.
We lost power multiple times with the on-going after shocks. The emergency generators didn’t always kick in (we know now that debris in the diesel tanks clogged the pipes when the shocks were really violent) and so we were frequently plunged into darkness – 20 resus bays all full of severely injured patients and suddenly it’s pitch black – that’s not a whole lot of fun! Headlamps are now also in the disaster packs!
Registration and tracking of patients was a major issue and one that we improved during the night. As computers were down for a long time, all registration and tracking of the patients was by hand and loaded into the computer at a later date. One hundred and thirty-one patients were registered in the first hour but probably another 100 or so were treated but not recorded. Eighty-seven patients registered in the second hour. During the night, it became apparent that we couldn’t account for many patients – it was unclear whether they were admitted or discharged. We solved this by placing students on the two exits and recording all details. These details were entered into the computers when we had power. This greatly aided on-going care and was also important for reconnecting families.
We also used students for lots of ‘gopher’ jobs, e.g. runners for each trauma bay, fetching blood from the lower ground floor, taking phone results, raiding the cafeteria to feed the staff, making up kits for hyperkalaemia treatment, and restocking supplies.
Whenever something wasn’t working a few senior clinicians would get together in a huddle, make a new plan and announce it over the Tannoy. This improvisation was a key ingredient for the on-going running of the hospital.
At no stage could we predict what was coming – ambulance control was severely damaged in the CBD. Attempts were made to control the response from Auckland (a city 1000km away). The later waves of patients were worse as they had been crushed for long periods. With this came the complications of crush – life threatening hyperkalaemia, rhabdomyolysis, compartment syndrome, multi-organ failure and amputations. Patients kept arriving, aftershocks continued and staff kept working. Cell phones were mostly down with only intermittent texts coming through. Most of us didn’t know if our families and friends were safe.
During all that adversity I will never forget the glimpses of bravery, fear, stoicism, determination and cohesion on the sea of faces in the department – all working together to help in any way they could.
I think the biggest adjustment was that the earthquake wasn’t just an external event. We, as individuals and the organisation as a whole, were all part of the disaster. This added an enormous strain to the working environment. Our waiting room roof in ED collapsed, the top two floors of the hospital flooded and had to evacuate, at several stages we thought the whole hospital would have to evacuate. Multiple services were compromised. We had frequent big aftershocks and multiple episodes of loss of power and darkness. All this adversity and yet everyone continued to do their job, each little cog providing a vital link so that the whole wheel was turning as one. In this way we not only looked after so many patients but also each other.
As 24 hours came up we used the last of the 365 pre-packaged disaster packs. Hundreds of other patients were treated outside the ED and around town. One hundred and eighty-two people died (USAR workers claim it’s a miracle this wasn’t over 1000) but only six of these died in hospital. I think this speaks volumes for the care patients received.
The contact and support we received from colleagues and friends within our country and all around the world was heart-warming.
Aftershocks continued with no warning or rhythm. A ‘new normal’ state ensued: Sleep deprivation from constantly being jolted awake; no tap water, sewerage or power for many; dust in the air; Police, army personnel and tanks guarding the streets; streets cordoned off, road cones highlighting sinks in the roads; taking three times longer than normal to get somewhere whilst navigating road closures and broken roads; helicopters flying overhead to assess damage; a whole new vocabulary of words to learn such as aftershocks, geonet, liquefaction, earthquake commission; strangers saying hello, asking how you were and genuinely meaning it.
It’s now eight months post-22 February. It’s hard to know how to sum up my feelings – surreal, horrific, and terrifying and yet our team hung together amongst all that adversity, doing what we could to help the hundreds injured. I love trauma but I have seen things I never want to see again.
The enormous pride in seeing the way everyone worked in together has left me feeling hugely humbled and actually privileged to have been involved. Hospitals and how they function is so much about the good will and camaraderie of the people within it.Things are tough here. I have been homeless since the event. We are still waiting a decision about whether the apartments are going to be demolished or can be fixed! I have spent the year sharing my six-year-old nephew’s bunk beds. The in limbo state isn’t a lot of fun. I keep trying to remind myself that at least all my friends and family escaped unharmed and so the other stuff is manageable… works most of the time! The enormity of the damage is huge and will take a long time to rebuild here, but time is a wonderful healer. Mostly, spirits remain stoic and people are indeed resilient. The aftershocks seem to be settling but just last week we had another 5.5 earthquake. We are all trying to go forward but is it over? … I hope so, but have no idea.
Jan Bone, Emergency Physician, Emergency Department, Christchurch Hospital, New Zealand