AAbbssttrraaccttIntroduction: On January, 2011, a devastating

tropical storm hit the mountain area of Rio de JaneiroState in Brazil, resulting in flooding and mudslidesand leaving 30,000 individuals displaced.

Objective: This article explores key lessons learnedfrom this major mass casualty event, highlighting pre-hospital and hospital organization for receiving multi-ple victims in a short period of time, which may beapplicable in similar future events worldwide.

Methods: A retrospective review of local hospitalmedical/fire department records and data from theHealth and Security Department of the State were ana-lyzed. Medical examiner archives were analyzed todetermine the causes of death.

Results: The most common injuries were to theextremities, the majority requiring only wound cleaning,debridement, and suture. Orthopedic surgeries were themost common operative procedures. In the first 3 days,191 victims underwent triage at the hospital with 50requiring admission to the hospital. Two hundred fiftypatients were triaged at the hospital by the end of thefifth day.The mortis cause for the majority of deaths wasasphyxia, either by drowning or mud burial.

Conclusion: Natural disasters are able to generatea large number of victims and overwhelm the mainchannels of relief available. Main lessons learned are asfollows: 1) prevention and training are key points, 2) keymeasures by the authorities should be taken as early aspossible, and 3) the centralization of the deceased in onelocation demonstrated greater effectiveness identifyingvictims and releasing the bodies back to families.

Key words: landslide, disaster medicine, mudslide

IInnttrroodduuccttiioonnOn the night of January 12, 2011, a devastating

tropical storm hit the mountain area of Rio de JaneiroState in Brazil (~2,100 m above the sea level). Localauthorities recorded a volume of 180 mm of rainwaterin 30 hours (130 mm in 24 hours), resulting in floodingand mudslides, more than 30,000 were persons dis-placed, 700 were injured, and there were 845 immedi-ate deaths. One year after the disaster, the number ofdead and missing persons was estimated to be 1,300.

In this particular natural disaster, sequentialland/mud avalanches struck different geographiczones affecting more than 800,000 inhabitants (inthree cities, four strikes). The event overwhelmed localemergency medical services, regional hospitals, andfire and police stations.The result of mudslides and theincredible volume of rainwater over a short time periodresulted in devastating floods that uprooted trees, tele-phone and electric poles; damaged water and fuel lines;and impassable roads and bridges which severelyneeded recovery efforts. Communication was badlyaffected because of the lack of electricity in the crashedregion as well as cell phones signals (Figures 1 and 2).

This article explores key lessons learned from thismajor mass casualty event, highlighting the preparinggaps for effective response in the following three majorareas: 1) emergency medical care delivery, 2) evacua-tion and housing for displaced persons, and 3) man-agement of mass fatalities.

MMeetthhooddssA retrospective review of local hospital medical

records, fire department (FD) records, and data from

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Lessons learned from a landslide catastrophe in Rio de Janeiro, BrazilBruno Monteiro Tavares Pereira, MD, MSc; Wellington Morales, MD; Ricardo Galesso Cardoso, MD; Rossano Fiorelli, MD, PhD; Gustavo Pereira Fraga, MD, PhD; Susan M. Briggs, MD, MPH

ORIGINAL ARTICLE

DOI:10.5055/ajdm.2013.0000

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the Health and Security Department of the State wereanalyzed. News media resources were also used to eval-uate this mass casualty incident (MCI). Hospitalrecords and government data were used to provideaccurate information regarding hospital triage, types ofinjury, need for surgery, patient transfers, and theextent of hospitalization. Medical examiner archiveswere analyzed to determine the causes of death. Ananalysis was performed to determine where changes toexisting systems and protocol refinements were needed.

MMeeddiiccaall rreessppoonnssee ttoo tthhee ddiissaasstteerrThere were no official disaster plans for the region.

The majority of healthcare providers had little or no train-ing in disaster management or MCI medical assistance.

American Journal of Disaster Medicine, Vol. 8, No. 3, Summer 201322

Figure 1. Affected cities in the State of Rio de Janeiro.City One: Petropolis; City Two: Teresopolis; CityThree: Nova Friburgo.

Figure 2. Mudslide strike and flood.

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Field triage was initially performed by volunteers (neigh-bors, friends,and family), due to inaccessibility of affectedareas thereby including the ability of response personnelto rapidly respond, two hospitals in all three affectedcities provided medical care for victims of the disaster.The main one and closest to the disaster zone was a 137-bed hospital with five operating rooms (Figure 1:Teresopolis/city 2). This institution was able to continueto function with power supplied by two diesel energy gen-erators. The chief of the Emergency Room was trained inMCIs and was on service the day of the event. Under hiscommand and before receiving any official warning aboutthe incident, but expecting the worst, the emergencydepartment team started to prepare for receiving multi-ple victims and functioned as the hospital IncidentCommand location, even though no plan was previouslyset for that. The ER team allocated patients to other sec-tors, defined an in-hospital triage zone, implemented animprovised triage method (red/yellow/green), enforcedsecurity, made cell phones contact with other regionalhospitals for receiving transferred patients (yellow), andcontacted blood banks. A nearby gymnasium was estab-lished to shelter victims triaged as green. The initialemergency team was composed of one surgeon, one anes-thesiologist, two GYO, one pediatrician, one critical carespecialist, and three GP’s, plus the chief of the ER.

Around 6:00 AM, the first of many casualtiesarrived at the hospital, including a 9-year-old boy.Three of those were triaged as green, identified (notincluded in hospital statistics) and dispatched to thegreen zone (gymnasium). Three patients were classi-fied as yellow and admitted. The last admitted patientwas classified as red and admitted to the intensivecare unit. Two of these victims required surgery(orthopedics). Even though no official disaster planwas set, the fact of one medical team member beingpresent at the hospital with disaster preparednessproficiency helped in in-hospital mass casualty man-agement and naturally became a local leader. Afterpower was reestablished, television began broadcast-ing news about the incident and its magnitude andseverity. Hospital employees (administrative, health-care providers including surgical specialists, andcleaning personnel) voluntarily started arriving at the hospital, reinforcing the multidisciplinary team

already in place. At 8:00 AM, an official report from theFD came through a FD ambulance reporting the mag-nitude of the disaster scenario and its severity.

Large numbers of victims were brought by commu-nity volunteers’ in the back of trucks, immobilized usingdoors as backboards, and carried in homemade stretch-ers in some cases using mattresses, clothing, and piecesof wood. Dead bodies found at the scene were brought tothe hospital by volunteers, triaged as black and for-warded to a zone outside the hospital in the same vehi-cle they arrived for identification and storage, as noofficial transport for decedents was available by thattime. In the first 24 hours, 136 patients were triaged asred or yellow. As many patients as possible were identi-fied, including those not admitted (green).

Eleven patients needed surgery, nonurgent sur-gery cases were transferred to other nearby institu-tions on the second or third day. The most commoninjuries were to the extremities, with the majorityrequiring only irrigation, debridement, and suture.These patients were discharged on the same day,relieving ER congestion. Patients in need of surgery,critical care or infirmary admission never returned tothe ER (one-way triage of patients).

FFeeddeerraall ggoovveerrnnmmeenntt aassssiissttaanncceeMilitary and government support started arriving

at the disaster zone at the end of the first day, as wellas tons of donations (clothes, food, and personalhygiene supplies). Helicopters helping in rescues andto transport supplies were sent to safe areas. TheNavy force and the Rio de Janeiro State FireDepartment built campaign hospitals (Figure 3), anda field Incident Command was created by all rescueforces involved. Water was suspended for 24 hoursuntil analysis of contamination was evaluated.

Stations for ambulatory medical assistance (vac-cine and infectious disease control), psychologicalassistance and office stations to provide new ID docu-ments, government financial help, and home alloca-tions were built.

HHoommeelleessss aallllooccaattiioonnDisplaced casualties from these three major

affected areas were dispatched to several gymnasiums

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for shelter. Security was reinforced in the gymnasiumperimeter and only authorized personnel were able toenter the area. An area of a basketball court was usedas a rest area. No food was allowed in this area, in anattempt to have optimal environmental control. Thebleachers were used as storage for food and clothes,separated in predetermined sections. Men and womenused the gymnasium lockers for personnel hygiene.Military personnel guaranteed organization, security,food and water supply to each shelter.

On the third day, 4,000 homeless or displaced peo-ple had already been registered at the gymnasiums.Animals were gathered, identified when brought byfamilies and placed in veterinarian shelter.

MMaannaaggeemmeenntt ooff ddeecceeddeennttssAll decedent remains were allocated in the same

nonrefrigerated area. A medical examiner office fromthe capital of the State offered support for identifica-tion (photos, digitals, dental studies, and DNA sam-ples) and forensic examination, respecting all legaland customs issues. Bodies were separated by geo-graphic origin as they were brought in by search andrescue teams to later identification by families.Nearby, a victim identification office was built, and alist of identified bodies was posted.

Once recognition was established, authoritieswere able to use morphological data and picturesbrought by victim’s families for body identification. If

the identification matched all the data, the body wasthen shown for family recognition. All bodies wereplaced in coffins provided by the municipality anddelivered to funeral homes when claimed by families.As body management was centralized in one place, theidentification process was expedited. Local authoritiesoffered psychological and grief support. Judicial offi-cials provided the necessary administrative docu-ments (ie, death certificate).

The cause for the majority of deaths was asphyxia,either by drowning (25 percent) or mud burial (75 per-cent). Traumatic injuries were observed in one third ofthe victims, but were not determined as the cause ofdeath in any cases.

American Journal of Disaster Medicine, Vol. 8, No. 3, Summer 201344

Figure 3. Brazilian Navy campaign hospital units.

12 Lessons learned from this MCI & plan gaps

Community Volunteers are the first to respond at scene: theycan be useful in helping rescue teams in minor activities

Communication between all involved teams and definedareas (such as incident command unit, rescue teams, hos-pitals, medical examiner office, and shelters) is essential

A Command Incident algorithm must exist and be readyin a MCI

Authorities must have a disaster plan and recognize riskareas to avoid worse scenarios (key measures to keep lifesustainable)

Emergency hospitals must have their own disaster planswith each involved person having functional duties asdefined by the incident Command System

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DDiissccuussssiioonnThis article demonstrates lessons learned from a

devastating natural disaster that involved three citiesand a population of 800,000 inhabitants in the State ofRio de Janeiro, Brazil. This disaster resulted in a largenumber of homeless and fatal/nonfatal victims. Theregion affected by the storm was a poor region with fewresources. The trauma system is very nascent or nonex-istent, and there was no local plan to respond to disas-ters. Except for personnel of the Fire Department, fewindividuals had any predisaster training or experience.

Accidents with multiple victims require continuoustraining and exercises.1,2 All disasters have commonmedical and public health concerns as well as uniquerisks related to geographic, social, economic, or politicaldifferences. The event described in this study occurredaround midnight, affecting entire families. Much of thehillside that collapsed was illegally occupied and disor-derly, without prior planning for water runoff, therebyincreasing the chances of a catastrophe. The immensityof the problem prevented the immediate arrival of spe-cialized forces, worsening the situation of the victimsinvolved. Disaster prevention plans, as well as disasterresponse, should be a priority of the authorities toreduce the incidents of fatal and nonfatal casualties.

Volunteers, who were involved in the disaster butdid not get injured, performed the initial rescue. Thepresence of volunteers is acceptable and described in

the literature, but caution is needed.1,2 Volunteers arenot experts and often become victims due to lack ofknowledge of scene safety. The fact that they are nottrained and do not perform effective triage decreasesthe effectiveness of the disaster response.

In this event, despite little experience with disas-ter management and almost all rescue forces beingaffected by the disaster, local authorities and hospitalreference relief organized themselves well and pre-pared for the reception and processing of multiple vic-tims. A triage unit at the hospital entrance can greatlyhelp in correcting over-triage, which often occurs inthe field by nontrained personnel.4,5 In less than 24hours, several units of government rescue, civiliansand military, were ready to assist victims, electricitywas reestablished and the most common forms of com-munication made available.

The first 24 hours were undoubtedly the biggestchallenge in this event in all instances. Military aid isessential in this type of disaster, especially when thecommon means of movement have collapsed, such ashighways, streets, and bridges. The use of rotary wingaircraft becomes mandatory for effective resolution ofa natural event that assembles.6

The concern by the authorities such as shelter, food,water and personal hygiene, infection control, psycholog-ical support, and security are critical to maintainingorder and minimize the effects of the disaster.4,7-11 In thisevent, in the mountainous region of the State of Rio deJaneiro, shelters were identified and controlled accessimposed. All volunteers working on site, as well as disas-ter victims present in the shelters, were properly identi-fied. These measures were sufficient so that authoritiesrecorded no violent acts. The delegation of activities wasto help everyone present in shelters shift their focus fromthe catastrophe to a motivational activity, which alsohelps in the psychological recovery of victims.11,12

Care of the fatal victims involved, respecting allfaiths and beliefs, and the availability and quick accessto information about the deceased assisted in the under-standing of the population and comprehension of thesteps necessary to identify all the bodies.The centraliza-tion of bodies into a large shed and additional forensictrained staff expedited the identification of the bodies.The cross-match of pictures delivered by relatives, with

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12 Lessons learned from this MCI & plan gaps (continued)

A triage unit at the disaster referenced hospital helps incorrecting over-triage

Trained teams are the key point of successful disaster relief

Military forces are helpful in most rescue operations andsupport logistics

Shelters must be fast provided and security reinforced

Allocating dead bodies in a single designated facility facil-itates identification, and family body claims

Digital pictures of the bodies can help family identifica-tion faster

After the first 24 hours, the number of nonfatal victimsdecreases

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photographs of bodies taken by forensic technicians, wasan easy and inexpensive method to identify many of theunidentified bodies, saving more complex processes suchas dental analyses and DNA for those really needed.11-15

Another useful method to help with the identification ofbodies was splitting them by geographical region wherethey were found. In events with large amount of victims,this simple measure accelerates the identificationprocess.

We observed that, in this natural cause catastro-phe as in others, a great number of victims were deadat the scene due to the devastating force of the floodsand mudslides. Also, after the first 24 hours, the num-ber of nonfatal victims decreases and usually moreresources (human and material) are available. In thisMCI, local officials provided financial aid and housing,as well as documentations necessary for each citizen(identity, social insurance, and death certificates).

CCoonncclluussiioonnNatural disasters are able to generate a large num-

ber of victims and overwhelm the main channels of reliefavailable. Prevention and training is a key point; how-ever, in the absence of it, disaster recovery measures canbe taken. Even with little guidance and proper training,institutions can become organized for receiving simulta-neous, multiple victims. The presence of a leader canmotivate a multidisciplinary team and establish steps incaring for victims. Triage in the emergency departmentby experienced physicians is essential.

Key measures by the authorities should be taken asearly as possible, including reestablishment of basicmeasures to maintain life (electricity, food, clean water,sanitation, and shelter), adequate provision of traffic onroads, medical care, psychological, forensic and admin-istrative. The centralization of the deceased in one loca-tion demonstrated greater effectiveness to identifyvictims and to release the bodies back to families.

Bruno Monteiro Tavares Pereira, MD, MSc, Assistant Professor,Division of Trauma Surgery, Department of Surgery, School ofMedicine, University of Campinas, SP, Brazil.

Wellington Morales, MD, Associate Professor, Department ofSurgery, Teresópolis School of Medicine, Rio de Janeiro, Brazil;Chief, Clinics Hospital of Teresópolis Emergency Department, Rio de Janeiro, Brazil; Surgical Activities Coordinator of theHealth and Security Rio de Janeiro’s State Department, RJ, Brazil.

Ricardo Galesso Cardoso, MD, G.R.A.U. Flight Doctor (HEMS), Fac-ulty of the Division of Trauma Surgery, Department of Surgery,School of Medicine, University of Campinas, SP, Brazil.

Rossano Fiorelli, MD, PhD, Faculty of the Department of Surgery,School of Medicine, University of Rio de Janeiro, RJ, Brazil.

Gustavo Pereira Fraga, MD, PhD, Chief, Full Professor of Surgery,Division of Trauma Surgery, Department of Surgery, School ofMedicine, University of Campinas, SP, Brazil.

Susan M. Briggs, MD, MPH, Associate Professor of Surgery, Mass-achusetts General Hospital, Harvard Medical School, Boston,Massachusetts.

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