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The Dragon Strikes: Lessons from the Wenchuan Earthquake

Chen, Guo MD*; Lai, Wei MD*; Liu, Fei MD*; Mao, Qingxiang MD; Tu, Faping MD‡§; Wen, Jin PhD; Xiao, Hong MD*; Zhang, Jian-cheng MD; Zhu, Tao MD*; Chen, Bin MD; Hu, Zhao-yang PhD*; Li, Rong-Mei*; Liang, Zhi MD#; Nie, Hu MD; Yan, Hong MD; Yang, Bang-Xiang MD*; Du, Quan MD; Huang, Wen-Xia*; Jiang, Yao-wen MD; Kwan, Anne Siu-king MD**; Song, Li MD*; Wu, Chao-Meng MD*; Xiang, Tia MD; Xu, Hong-wei MD*; Lau, Wayne Bond MD††; Song, Hai-Bo MD*; Wen, Chuan-Bin MD*; Yao, Zhen-Hai MD, PhD‡‡; Zhang, Lan MB*; Zeng, Jianrong MD§§; Dai, Yue-E MD*; Lopez, Bernard L. MD**; Zheng, Jian-qiao MD*; Zhou, Jihong MD; Christopher, Theodore A. MD**; Ma, Xin L. MD, PhD**; Yu, Hui MD*; Xu, Li-Li MD*; Guo, Qiao MD*; Song, Zhi-Ping MD*; Volinn, Ernest PhD∥∥; Kryger, King PhD; Cao, Yu MD; Ge, Hengjiang MD; Liu, Hui MD*; Luo, Chao-zhi MD*; Tao, Weike MD§; Zuo, Yun-Xia MD, PhD*; Liu, Jin MD*

doi: 10.1213/ANE.0b013e3181cbc62c
General Articles: Special Article

Authors' affiliations are listed at the end of the article.

Accepted for publication November 12, 2009.

Study funding: Funding information is provided at the end of the article.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.anesthesia-analgesia.org).

King Kryger is the Writer and former Managing Editor of Anesthesia & Analgesia, Richmond, CA.

GC, WL, FL, QM, FT, JW, HX, J-cZ, and TZ are co–first authors.

YC, HG, HL. C-zL, WT, Y-XZ, JL are co–senior authors.

Address correspondence and reprint requests to Jin Liu, MD, Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China. Address e-mail to scujinliu@yahoo.com.cn.

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 & Analgesia solicited articles from Chinese anesthesiologists personally involved with the immediate rescue or long-term care of victims of the Sichuan earthquake.

Collectively, these articles describe important lessons learned by medical personnel, many of whom risked their lives to provide medical care to survivors at the earthquake's epicenter, and draw on the experience of other physicians treating the thousands of injured survivors after the devastation. The articles have been combined into a single narrative in this special article. The original submissions may be viewed in their entirety online as a supplement at www.anesthesia-analgesia.org.

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THE DRAGON STRIKES

Along the broad eastern edge of the Tibetan plateau, the “roof of the world,” lie the Longshan (“Dragon's Gate”) mountains and the Longshan thrust fault that created them. On May 12, 2008, at 14:28 local time, this fault ruptured in several places along its 155-mile length, causing a massive earthquake registering 8.0 on the Richter scale (Figs. 1 and 2). The quake lasted about 2 minutes and struck with a force 30 times greater than the 1995 Great Hanshin earthquake near Kobe, Japan, that killed 5100 people. Within hours, >69,000 people were dead, nearly 400,000 injured, and millions displaced in what experts have called the 11th deadliest earthquake on record (Table 1, No. 1). Moments after the quake, thousands of victims lay trapped in collapsed buildings, and landslides blocked all roads into the mountainous zone of the epicenter (Fig. 3).

Figure 1

Figure 1

Figure 2

Figure 2

Table 1

Table 1

Figure 3

Figure 3

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THROUGH THE DRAGON′S GATE

As soon as news of the quake arrived at Daping Hospital in Chongqing, 250 miles from the epicenter, a medical rescue team began mobilizing to go to the epicenter at Wenchuan. The experience of this group typifies the frustrations awaiting rescue and relief workers (Supplement 1, see Supplemental Digital Content 1, http://links.lww.com/AA/A64).

The Chongqing team, comprising 27 medical personnel, including 3 anesthesiologists, set out for the epicenter about 22 hours after the initial quake. They had no way of knowing the extent of the devastation that awaited them, because most of the communication infrastructure in Sichuan Province had been destroyed. Entire counties in the impact zone could not be reached (Supplement 2, see Supplemental Digital Content 2, http://links.lww.com/AA/A66) (Table 1, No. 2). Seven hours later when they reached Dujiangyan, halfway to the epicenter, they began to appreciate the magnitude of the disaster (Fig. 4).

Figure 4

Figure 4

They discovered that thousands had been killed in Dujiangyan, including hundreds who died in the collapse of a hospital, and some 1000 students who were killed when their school buildings collapsed. Although the scene that greeted these medical relief workers was grim, it represented only a small part of the devastation elsewhere in the region.

In addition, the Chongqing medical team discovered that their preparations had been inadequate, including an absence of an emergency generator, water purification equipment, satellite communications equipment, and drugs to protect the team against diseases such as visceral leishmaniasis.

The Chongqing medical rescue team also encountered significant obstacles to reaching victims, including aftershocks and unpredictable landslides. They had to take a detour of >600 miles to reach Wenchuan. Along the way, one of the team's minivans was crushed by falling rocks (Fig. 5) after a strong aftershock (Fig. 6). Fortunately, no one was seriously hurt, but thousands of people died in such landslides on roads elsewhere.

Figure 5

Figure 5

Figure 6

Figure 6

The Chongqing medical rescue team finally reached Wenchuan county seat 96 hours after the initial earthquake. There they found many traumatized and dehydrated victims in danger of wound infections and in need of immediate surgery. Nearly all equipment in local hospitals, including laboratory and imaging equipment, had been destroyed, but some monitors, anesthesia machines, surgical dressings, and instruments were still available.

The difficulties experienced by the Chongqing medical rescue team underscore 2 of the most medically significant aspects of this disaster: (1) the delay in reaching and treating the injured, and (2) the need to transport many victims out of the region.

With many hospitals destroyed (Fig. 7) and medical personnel killed or injured, those in need of treatment often had to make their way without assistance to the nearest undamaged facilities. Many of these patients flooded into West China Hospital in Chengdu. This facility, about 60 miles from the epicenter, has 4300 beds and is among the largest and most advanced diagnostic and treatment centers in China. The Department of Anesthesiology includes 55 attending physicians and >150 residents. Many of the lessons learned from the quake in Sichuan come to us from the faculty of this department and are presented here. The first lesson, as stated by one author in this group, is that in such a disaster, one must remain safe to help others and not become an additional casualty.

Figure 7

Figure 7

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CRITICAL LESSONS

Review Hospital and Operating Room Seismic Safety and Train Operating Room Physicians in Emergency Medical Procedures

Dr. Yunxia Zuo, Vice-Director of the Department of Anesthesiology, was at work in her office at West China Hospital when the building began to shake. She left her office and found a chaotic scene, with surgeons, anesthesiologists, and nurses scrambling toward nearby stairwells. Dr. Zuo urged them to shelter in small rooms such as closets and bathrooms rather than in stairwells, which could have proven unstable and dangerous. Some listened to her but others just went down whatever staircase they could find. Most operating room (OR) personnel stayed with their patients, sometimes after an initial period of taking cover. And most of them, although frightened, continued their clinical work until they could be relocated outside or elsewhere (Yunxia Zuo, MD, PhD, e-mail communications, June 11, 2009).

It may have been Dr. Zuo's experience in those first frantic moments immediately after the quake that inspired the study she and her colleagues conducted several weeks later (Supplement 2). They sought to document OR conditions and the behavior of medical personnel throughout Sichuan Province at the time of the disaster. To determine what happened to them and their patients that afternoon and how their facilities held up after the earthquake, researchers and statisticians from the West China Hospital Department of Anesthesiology sent a 64-item questionnaire to department heads in 237 large and medium-sized hospitals in Sichuan. Only anesthesiologists who had been working in ORs at the time of the quake were invited to respond. Data gathered from 220 responses revealed that the reactions of the staff at West China Hospital were fairly typical of what went on in ORs elsewhere in the region. The 220 responses documented that at the time of the earthquake, there were at least 600 surgeons, 350 anesthesiologists, and 420 nurses at work in ORs around the Sichuan province. The actual numbers are higher because not all hospitals responded to the survey. Unfortunately, however, only 36.5% of the hospitals located in the zone of the epicenter could contribute to the survey because some hospitals in the area had been totally destroyed. The loss included an estimated 260 medical personnel killed and 780 injured (Yunxia Zuo, MD, PhD, e-mail communication, June 4, 2009).

In the ORs that did not collapse, the most dangerous structural damage was to mechanized doors that could not be opened (25.5%). More than 30% of these ORs lost electricity and almost as many lost their oxygen supply. Most anesthesiologists remained with patients. Nearly all reported feelings of fear and helplessness. Not surprisingly, those who had received some previous emergency fire and earthquake training reported feeling calmer, more confident, and less helpless than those who had not received such training.

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Review and Evaluate Triage Procedures in Preparation for Large-Scale Disasters

When the temblor struck, Dr. Jin Liu, Chair of the Department of Anesthesiology at West China Hospital, rushed to check on the ORs where 55 procedures (including 45 patients under general anesthesia) were then in progress (Supplement 3, see Supplemental Digital Content 3, http://links.lww.com/AA/A67), and because of concern that the department might soon be overwhelmed with injured patients, decisions had to be made as to which operations to continue and which to terminate (Yunxia Zuo, MD, PhD, e-mail communication, June 4, 2009).

Before long, a flood of victims began pouring in from the most severely affected areas in the mountains. The casualties came to West China Hospital in waves, arriving first via helicopter and several days later in vehicles after the army began to repair the mountain roads. Eight days after the quake, there was another major influx of patients, the result of triage efforts at an army airport, as well as transfers from nearby hospitals and emergency facilities. In the month after the earthquake, 2695 victims would be treated at West China Hospital and 875 quake-related procedures performed in the hospital's ORs (Supplement 3).

The large numbers of casualties streaming into West China Hospital and the severity and type of their injuries forced medical personnel to rethink their approach to triage. According to one group of authors (Supplement 4, see Supplemental Digital Content 4, http://links.lww.com/AA/A68), when there are so few facilities to care for so many casualties, medical care must focus on those who are most likely to survive rather than those who are most critically ill, with emphasis on efficient use of available resources and minimizing waiting time for victims likely to survive.

The West China Hospital group conducted triage in a 3-part process: (1) collecting physiological data including assessment of vital signs and level of consciousness; (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).

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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, http://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, http://links.lww.com/AA/A68, and Supplemental Digital Content 6, http://links.lww.com/AA/A70).

Figure 8

Figure 8

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, http://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

Figure 9

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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, http://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 designation, “oligoanalgesia,” is used to describe it (Table 1, No. 3). It is quite possible that the magnitude of the disaster and the sheer number of victims in pain simply illuminated and ampli-fied existing patterns of undertreatment. Whatever the causes, this study underscores the need for greater awareness that standard regimens for effective pain management after natural disasters are essential.

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Have Plans in Place for Organizing and Deploying All Available Personnel, Including Volunteers

One of the most impressive aspects of China's response was the speed and ingenuity with which thousands of people were put to work in the rescue and relief effort. Shortly after the earthquake, the Chinese government moved thousands of troops into the Sichuan province. As soon as weather permitted, helicopters flew to the interior of the quake zone and paratroopers jumped into the worst-hit areas to conduct rescue operations, repair roads, and manage security. In addition to welcoming hundreds of Chinese volunteers, the government opened its borders to medical personnel and rescue experts (Table 1, No. 4). Within a few days, 13 medical teams representing 10 countries had deployed around Sichuan. These groups set up field hospitals and established pharmacies, intensive care units, laboratories, and ORs. The first regional team arriving at West China Hospital, as one author notes, presented a significant challenge to the staff: “Huge numbers of people from various backgrounds, different styles of practice, and familiarity with different varieties of equipment posed a true challenge of cooperating effectively under such stressful circumstances” (Supplement 3). But the challenge was met, and by the time these medical teams left China, they had treated some 24,500 patients and performed 642 operations. They also contributed by conducting 3082 clinical rounds and 78 seminars and academic meetings attended by >2800 people (Supplement 8, see Supplemental Digital Content 8, http://links.lww.com/AA/A72).

Dr. Thomas Grissom, from the R. Adams Cowley Trauma Center at the University of Maryland, a specialist in critical care and anesthesiology, helped out at West China Hospital for several weeks after the quake. He praised the Chinese response to the disaster as very effective and “encompassing,” and noted that having the chance to work with Chinese physicians in the emergency department was deeply rewarding (Thomas Grissom, MD, personal communication, June 25, 2008). Dr. Thomas Scalea, who headed up the 5-member group, called their experience “an opportunity each of us will remember for the rest of our lives” (Table 1, No. 5).

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Summary of Critical Lessons

The optimal medical response to a major earthquake requires timely delivery and effective administration and deployment of appropriate drugs and equipment. Health care professionals engaged in rescue and relief efforts should be trained in emergency care and should be assisted by well-coordinated groups of other emergency response personnel. Attention must be given to ensuring that medical personnel work in a safe environment so that they can provide care for the casualties rather than becoming casualties themselves.

In addition to the lessons highlighted in this article, many more could be added, especially for personnel charged with aiding victims on site rather than in hospital. These would include plans for updating skills in regional anesthesia techniques and for providing first-responder assistance in situations whereby resources are limited or lacking altogether.1 The unique challenges of rescuing victims of crush injuries found after hours or days with sustained ischemic limbs must also be recognized.

Additional Web resources describing the earthquake and various aspects of the recovery are shown in Table 2.

Table 2

Table 2

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IN THE WAKE OF THE DRAGON

The damage caused by this earthquake was so staggering and widespread that the road to recovery for Sichuan Province will be long and difficult. Total infrastructure damage has been estimated at upward of 150 billion US dollars (Table, No. 6). Nonetheless, rebuilding continues and funding for this work has been generous. Although millions of people are still living in temporary housing, the International Red Cross reports that because of “an unexpectedly swift rate of reconstruction,” most will be moving into new homes by the end of this year (Table 1, No. 7).

The medical community too has begun the work of recovery. West China Hospital is putting the lessons learned during the quake into action. Guidelines for earthquake crisis management have been established and training courses are underway for staff anesthesiologists and those from the earthquake's epicenter zone (Yunxia Zuo, MD, PhD, e-mail communication, June 4, 2009). The hospital has developed a long-distance telecommunications network linking it with 29 affiliated hospitals in the region. This network has already provided teleconsultations, image transmissions, and treatment proposals for >1000 patients (Table 1, No. 8).

Most recently, West China Hospital management and staff have decided that the emphasis during the current stage of their medical relief work must be placed on physical and psychological rehabilitation. This decision no doubt reflects an understanding that although schools and hospitals will eventually be rebuilt, building codes updated, and displaced persons rehoused, many scars left by the quake are not as visible as collapsed buildings. As of this writing (2009), several sources, including the International Red Cross, have put the death toll at far greater than originally estimated (Table 1, No. 7). Although exact numbers are not yet available and are controversial, there is little doubt that many hundreds of these uncounted casualties were schoolchildren (Table 1, No. 9). The death of so many school-age youngsters throughout the province will have significant societal consequences, consequences that will be difficult to assess and challenging to ameliorate. The psychological effects of such a large-scale disaster and their long-term ramifications, although harder to quantify than damage to the infrastructure, are a stark reality.

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ADDENDUM

The Editorial Board of Anesthesia & Analgesia appreciates the contributions of our colleagues in China. Their willingness to provide multiple accounts of their experiences after the Sichuan earthquake has permitted our weaving their stories together to produce this article. However, the far greater contribution is the service provided their patients. Their selfless devotion to patient care, and their skill and dedication in the most horrifying of natural disasters, make us proud to be anesthesiologists.

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AUTHORS' AFFILIATIONS

From the *Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu; †Department of Anesthesiology of Daping Hospital, Institute of Surgery, Third Military Medical University, Chongqing; ‡Department of Anesthesiology, Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, China; §Department of Anesthesiology and Pain Management, The University of Texas Southwestern Medical Center at Dallas, Dallas, Texas; ∥The Chinese Evidence Based Medicine Center, West China Hospital, Sichuan University; ¶Department of Emergency Medicine, West China Hospital, Sichuan University; #Sichuan Provincial Health Department, Chengdu, Sichuan; **Department of Anaesthesiology, Pain Medicine and Operating Services, United Christian Hospital, Kowloon, Hong Kong, China; ††Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania; ‡‡Toronto General Hospital, Toronto, Canada; §§Wenchuan People's Hospital, Aba Prefecture, Sichuan, China; and ∥∥Pain Research Center, School of Medicine, Department of Anesthesiology, University of Utah, Salt Lake City, Utah.

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STUDY FUNDING

Supported, in part, by a grant from the Chinese Medical Board (no. 88-846), grant no. 30872435, from the National Nature Science Foundation of China, Beijing, China, and general support from the Medical Society of Sichuan Province, the Department of Anesthesiology of the West China Hospital of Sichuan University, and the Laboratory of Statistics of Sichuan University.

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REFERENCE

1.Yin Y, Zhu T. Ventricular fibrillation during anesthesia in a Wenchuan earthquake victim with crush syndrome. Anesth Analg 2010;110:916–7

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