No Survivors - Nothing to Do?
BRENDAN P. RYAN
Having been personally involved in the response to three major disasters - the Air India Jumbo Jet crash, the Pan Am Jumbo Jet incident at Lockerbie and the Armenian earthquake - I am no stranger to the comment, Of course, there was nothing to do - there were no survivors. This has usually been said to me when I have been exhausted from my efforts under difficult, unusual and often extremely distressing conditions. I want to point out that there is much for a doctor to do at a disaster, quite apart from saving lives. My experience has also taught me that there is no standard disaster and that we must therefore be prepared to learn from each others experi- ence. While many doctors, especially at present, are exposed to disasters, there are no experts.
How does the above comment, which often becomes a criticism levelled at rescue workers, arise? Firstly, there is professional jealousy. Whether one likes it or not, being involved in a disaster gives one a certain notoriety and this may lead to a curious form of simple jealousy. More importantly, the comment may come from those who have had to work harder to cover the absence of colleagues involved in disaster work. This kind of response can only be prevented by increasing the general level of understanding of disaster work and by good local planning and training for emergency work.
Secondly, there is the common assumption of those who do not have first hand knowledge of disaster work that
medicine at a major disaster is simply an extension of the doctors daily work. This is one of the reasons why improvements in disaster medicine are slow: it is assumed that we do it well enough already. In fact, most doctors have no idea what is required of them in a disaster. Even my chosen specialty of Accident and Emergency Medicine gives only a basic grounding in disaster work. Nevertheless, I believe that Accident and Emergency and Immediate Care Medicine can together form the solid base on which future disaster responses can be built.
To be effective, trained teams should be mobilising as soon as possible after a disaster has been declared. This will be at a time when misinformation is at its greatest and when official-sounding comments about the disasters geography and about the number of living and dead are being made with little or no factual basis. Rescue teams should not wait for a media con- sensus of opinion on survivor status, because it will then be too late to deliver immediate care. NO survivors must be a retrospective diagnosis, not an initial judgement on which the mobilisation of rescue teams is made to depend. One should not be deterred from rapid response by the fear of a false alarm, since false alarms give experience in themselves. It is characteristic of disaster that misin- formation, rumour and possibly even deliberate lying abound. If you get a call and you know the destination - GO!
So far as survivor status in concerned,
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no comment should be made until all have been seen and are known to be dead or alive. I will allow that if a plane drops out of the sky the probability of passenger survival is low, but what of those on the ground? And remember the Japan Air- lines Jumbo Jet that crashed into Mt. Osutaka on 12 August 1985. 520 pas- sengers were killed but four were brought to safety by rescuers. Even if only a small number of people can be helped, that is justification enough for a full response.
If all involved are dead, there is still much for the doctor to do. All must be pronounced dead and, especially if there is great dismemberment, other rescuers will be uneasy without a doctor present. There must also be someone available to sanction the sorting of bits of person from bits of masonry or aircraft. While acknow- ledging the need for this work to be done, many doctors will assume that there is "somebody else" to do it. I can assure them that there will be no queue of people waiting for this job, which will most usually be done by a frightened young policeman. The care of the living and the care of the dead must be carried on in parallel - it is not possible to take on one without the other. So there is a "package deal" of medicine to be prac- tised at a disaster which should be the responsibility of those with a vested interest in being present: the immediate care doctors. No other medical specialists will be present as early or be as well equipped with, for example, protective clothing and lighting. But this will not happen by chance. It requires planning and training in unusual circumstances.
During a disaster a doctor will work in circumstances and under stresses for which nothing but specific training will prepare him or her. He or she will be working with others even less prepared for these stresses, who will be very glad to have a doctor present, particularly one with special training and relevant experi- ence. (I am not talking here of psychiatrists, who have an important part to play later on.) Live casualties of a disaster should be seen by doctors with experience in the field, regardless of their parent specialties. "Multiple injury patients must be treated by the experienced, rather than used to gain experience" (D.W. Yates and A.D. Redmond, Lecture Notes on Accident and Emergency Medicine, Blackwell Scientific Publications, 1985, p.387).
It is a medical luxury to work as a doctor at a disaster where there are no survivors, and where one may therefore gain experience of those difficult circum- stances peculiar to disasters (e.g. unusual surroundings, darkness, poor weather) without the pressure of having to save or preserve life.
Brendan P. Ryan, M.B., F.R.C.S.I., Senior Registrar in Accident and Emergency Medicine University Hospital of South Manchester, U.K. Member, South Manchester Accident Rescue Team
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