Nepal is prone to various types of natural disasters due to its rugged and fragile geophysical structure; very high peaks; high angle of slopes; complex geology; variable climatic conditions; unplanned settlement; increasing population; weak economic condition; and lack of education and ignorance. Events of earthquake, flood and landslide are destroying the developmental infrastructure. In addition to this, thousands of people have lost their lives and countless cattle have been destroyed; lots of agricultural land and crops have been damaged too. These disasters cause a sudden disproportion between hostile elements of any kind and the survival resources that are available to counterbalance them in the shortest period of time. Disasters destroy organized community support mechanisms and result in an overwhelming number of casualties. They lead to sudden and significant disruption of normal community function and cause concern for the safety, property and lives of the citizens. Needs always exceed the available resources in these situations.
Disasters, manmade or natural, are frequently associated with mass casualty situations where the number of patients and the severity of their injuries exceed the capability of the healthcare facilities and staffs. During a mass-casualty incident (MCI), triage algorithm may be used to guide the allocation of limited healthcare resources. Triage is derived from the French word "trier", meaning "to sort", and refers to the process of sorting patients based on their severity of injury or illness. Triage ensures that constrained medical resources are directed at achieving the greatest good for the maximum number of people. Accordingly, mass-casualty triage does not always direct care to the most critically injured, but to those deemed most likely to survive with emergency aid. It applies to mass casualty situations, when conventional standards of medical care cannot be delivered to all victims. The goal is to optimize care for the maximum number of salvageable patients. Patients who will do well with minimum care are distinguished from those who will die despite intensive care. Attention is given to those who will benefit most from optimal care and rapid surgical intervention. Simply, patients sustaining major injuries who have the greatest chance of survival with the least investment of time, equipment, supplies, and personnel are managed first. Effective triage at the scene and within the medical institution is often a major determinant of outcome.
There should be preparedness to limit the impact of disaster events on people. It is a continuous cycle of planning, managing, organizing, training, equipping, exercising, creating, evaluating, monitoring and improving activities to ensure effective coordination and the enhancement of capabilities of concerned organizations to prevent, protect against, respond to, recover from, create resources and mitigate the effects of disasters. International Committee of the Red Cross (ICRC), in coordination with Dhulikhel Hospital (DH), has just trained twenty medical professionals in Emergency Room Trauma Course preparing them to combat with mass casualty situations. The training programme was conducted at Salambu Health Center, one of the outreach clinics of Dhulikhel Hospital. The programme was inaugurated by a representative from ICRC, Vice-Chancellor of Kathmandu University, CDO of Kavre district and chief executive officer of Dhulikhel Hospital (DH).
"When a calamity is really big, it exceeds the capabilities of the response because needs exceed resources, "Dr. Enzo Chemello from Italy (ICRC Surgeon, chief speaker in the training) said. "Even the most developed country cannot provide conventional standards of medical care to all victims during a situation of mass casualty. Triage is the best tool to be applied in every step of management of the casualty for the best utilization of the available resources."
The programme was co-facilitated by DSP Dr. Dipta Lama (Surgeon-Nepal Armed Police Force), Dr. Sangina Ranjeet (Anesthetist-DH), Dr. Rohit Shrestha (Orthopedic Surgeon-DH) and Dr. Sanu (MDGP-DH). Twenty doctors from different institutes - District Hospital of Ramechhap, Dhading and Rasuwa, Armed Police Force, Army Hospital, Community Hospitals and different Teaching Hospitals – attended the programme. The three-day programme included theoretical review with hands-on training. Simulations and mock drills were the major attraction of the programme where participants presented the best ways of the utilization of available resources in their hospital in handling mass casualty situations.
Most of the times, such a national level workshop is hosted at a very sophisticated hotel or resort. In addition to preparing the medical personnel for mass casualty management, this workshop explored the possibilities of the urban facilities in the rural part of our country. Salambu Health Center is located at Majhipheda VDC, north-east part of Kavre district, which is on the border between Kavre and Ramechhap. The Health Center was established in 2007 as one of the Outreach Clinics of Dhulikhel Hospital with the aim of providing preventive, promotive and curative services to 30,000 population of the remote parts of Kavre and Ramechhap districts. The workshop was hosted at Salambu Support Center, part of the Health Center, which has just started its activities. The Support Center houses sophisticated rooms, well equipped conference hall with standard hygienic canteen that can serve 50 persons at a single setting. Sashi Kumar Lal Karna, medical assistant from ICRC, was surprised with the existence of amazing infrastructure in a remote part of the country and wished to host similar activities at Salambu in the future. Salambu Support Center recently organized a trip to Sailungeswor Temple (SAILUNG) which the participants from Kathmandu, Bhaktapur and Dhulikhel liked very much.
Dr. Adhikari can be reached at menishef@gmail.com.
