The 12th of May was made national Disaster Prevention and Reduction Day in 2009, after the devastating earthquake that killed more than 80 000 people (Centre for Research on Epidemiology of Disasters (CRED), 2011). On the same day in 2009 the Chinese government published its first white paper on disaster prevention and reduction (Chinese Government's Official Web Portal, 2009). Establishing an emergency rescue and disaster relief response system and improving the quality of disaster relief personnel identified as ways to enhance the disaster reduction capability. This paper suggests six key areas in the disaster education for pre-hospital medical personnel in China based on the gaps identified from literature published from the 2008 Sichuan Earthquake.
Disasters in China
China is a country frequently affected by both natural and man-made disasters. For the last ten years, the Sichuan earthquake in 2008 and the Qinghai earthquake in 2010 accounted for the first and second largest death toll in China respectively (CRED, 2011). From a literature review of health impacts of earthquakes in China from 1906–2007 (Chan et al, 2010), it was found that earthquakes regularly affect the vast Tibetan plateau and southwest Yunnan province but were relatively rare in central China and along the eastern seaboard. There were a larger number of deaths found at the extremes of age, and poor anti-seismic capacity of buildings and high population density were the leading causes of death for lower and higher seismic earthquakes respectively. While earthquakes have caused the largest number of deaths, flooding has repeatedly claimed many lives especially in the years of 2002, 2003, 2007 and 2010 (CRED, 2011). Technological disasters like industrial accidents occurred frequently in provinces with high economic activities, with heavy industry like mine ores and coal extracts accounting for most number of deaths (Chan and Griffiths, 2010; Chan et al, 2011). Therefore it is of paramount importance that the pre-hospital first respondents are able to respond to these disasters in order to minimise the number of lives lost.
EMS in China
The emergency medical services (EMS) in China are fragmented with large variations across different regions (Hung et al, 2009). Pre-hospital medical services are considered as the initial part of the emergency department response with staff that interchange between the two arenas. Paramedics is not a recognised profession in China, and the ambulance is typicallystaffed by an emergency physician, an emergency nurse and a driver. There is no uniform level of training for these pre-hospital personnel and their level of competency varies hugely from area to area.
The importance of training for EMS responders
In a survey of more than 21 000 US nationally certified EMS professionals (Fernandez et al, 2011), 91 % of respondents reported receiving at least one hour of individual-level preparedness training, and 60 % participated in at least one multiagency disaster drills in the prior two years. Fernandez et al (2011) found that hours of individual-level preparedness training were significantly correlated with the perception of preparedness.
In Germany, where ambulances are also staffed with emergency physicians like China, pre-hospital emergency physicians have specific training requirements for disaster relief operations. Seeing that the aim of their EMS system is to bring the resuscitation room to the patient, they are equipped with ALS ambulance, pre-hospital emergency physician, helicopter and other services (Fischer et al, 2011). It should be noted that ‘emergency physicians’ in Germany are usually trained anaesthesiologists or surgeons who have done additional training in pre-hospital care, and this does not equate to the Anglo-American model of predominantly hospital based emergency physicians. Their patient will be transported to the nearest appropriate hospital rather than the closest facility. During disaster relief operations, the prehospital emergency physicians must have attended special training or a two year training course. While emergency physicians have an 80 hour course taught from an interdisciplinary point of view, senior emergency physicians have in addition 40 hours of theoretical and practical training after a minimum of three years of practice in rescue services.
Disaster training and education framework
Regarding the content of the training, core competencies required for disaster response published in the US and internationally (Subbarao et al, 2008; Schultz et al, 2011) provided valuable suggestions for developing the Chinese standards. A literature review conducted in 2007 (Daily et al, 2010) found 38 articles describing competencies for healthcare professionals, but the number of papers specifically for paramedics are limited. The review found inconsistency in both terminologies and structure, resulting in a lack of universal acceptance and application.
Schultz et al (2011) recently produced a training framework for acute medical care personnel including emergency department nurses, emergency physicians, and out of hospital EMS personnel with 19 domains, 19 core competencies, and more than 90 performance objectives. This training framework has been created using a modified Delphi approach with representatives from multiple academic and provider organisations, and it has been endorsed by the American College of Emergency Physicians. Subbarao et al (2008) presented the education framework of the American Medical Association Centre for Public Health Preparedness and Disaster Response expert working group for all health professionals. This framework was created also using literature review and Delphi process, and contains seven core domains (see below). These core and specific competencies are adapted to three different levels for informed worker/student, practitioner and leader.
The seven core domains of the education framework of the American Medical Association Centre for Public Health Preparedness and Disaster Response expert working group for all health professionals presented by Subbarao et al (2008):
These frameworks have not only highlighted the different areas of domains and competencies required, but also the need for multiple tiers of training for the different level of responders. Specifically it is important for the managers to get familiar with the expected roles of EMS highlighted by the National Association of EMS Physicians (Catlett et al, 2011) in disaster preparedness and response. For preparedness, strategies highlighted include the adoption of an incident command system (ICS), development of well-defined emergency operation plans, stockpiling of supplies and equipments, and establishment of reliable communication systems. Furthermore, the issues on quality and legal concerns has made the development of performance metrics and the planning for liability issues important areas to be established.
The Institute of Medicine committee of experts on crisis standards of care (2009) proposed guidance for establishing crisis standards of care for use in disaster situations. The guidance recommended the principles on consistent state protocols, community and provider engagement, adherence to ethical norms, legal protection for healthcare practitioners and institutions, consistency in implementation, and ensuring intrastate and interstate consistency for the development of these standards of care.
Nuclear, biological or chemical (NBC) incidents require specialised skills for pre-hospital medical personnel. Waeckerle et al (2001) from the American College of Emergency Physicians Task Force of Health Care and Emergency Services Professionals on Preparedness for Nuclear, Biological, and Chemical Incidents produced an executive summary on the training requirements. However, this article will focus on natural disasters and earthquake situations and will not discuss NBC incidents in detail.
Disaster training components for China: from the experience in 2008 Sichuan Earthquake
The following text describes the six major areas of training for responders based on the 2008 Sichuan earthquake.
1. Disaster management
1a. Command and control system
It is essential that the disaster training components be well suited for responders working in the local context and its healthcare system. The 2008 Sichuan earthquake was one of the most devastating disasters in Chinese history, and challenged the response of the EMS system. Dai et al (2009) provided an overview of disaster response after the earthquake. Within hours of the disaster, the ‘Medical Care Assurance Group’ of the ‘12 May Sichuan Earthquake Relief Headquarters’ was set up and 28 ambulances with 90 medical and disease control staff were dispatched to different areas. The second and third batches consisting of more than 700 medical staff were sent for rescue work by midnight and the next morning. Tent hospitals had been set up at Anxian, Mianzhu and Dujiangyan 48 hours after the earthquake for early and accessible treatment.
Zhang et al (2011) reported there were reaching 18 000 health professionals at the Wenchuan earthquake site, including 10 630 domestic health professionals, 7 061 supporting military health officers and 350 international health workers. Due to the problem with access to earthquake victims, it took two weeks for the EMS providers to cover the entire disaster area. The number of injuries and deaths reported continued to increase until the end of the second week. Facing huge medical needs, the medical response was coordinated under the ‘System of Emergency Response Command with Mianyang Headquarters for Earthquake Disaster Relief’ and ‘Sichuan Medical Rescue Group for Earthquake Disaster Relief’ (Lei et al, 2008). Such structure was necessary to facilitate the command and control, and resembles the ICS commonly used in the US.
The 12 groups in the command chain under this structure include:
1b. Timeliness of deployment, logistic and backup support
Problems of self sustainability, communication and coordination were commonly reported among many medical teams on the ground (Yao and Lan, 2008; Zhu et al, 2008; Xu et al, 2009). Hou and Fan (2008) published an article on the efforts of the China International Search and Rescue Team in the Sichuan earthquake. Because of the support by military aircraft, the team was able reach the site of the collapsed secondary school from Beijing nine hours after the earthquake. Their team had 187 staff with 22 medical staff from a range of clinical medical specialities. They served at five sites for rescue, but also performed other medical tasks including assisting local hospitals in resuscitation of critical patients, performing minor operations, outreach clinics, prevention of infectious disease and psychological counselling.
International search and rescue teams like the Chinese team are part of the International Search and Rescue Advisory Group (INSARAG) of United Nations (UN) Office for the Coordination of Humanitarian Affairs (OCHA), and follow the guidelines of INSARAG (2011). Under the requirements in this guideline, the issues about self sustainability in terms of food, water and logistic support of these teams are specifically addressed, along with other essential components for team functioning including safety and security, communications, media guidelines and ethics considerations. This guideline may serve to remind the team requirements in the field.
1c. Fostering of military–civilian partnership
The Chinese People's Liberation Army (PLA) and the military hospitals played an important role in the rescue and medical response in Sichuan earthquake. Military medical teams were better prepared, with improved mobility and command structure (Huang and Zhu, 2009). Huang and Zhu proposed different models of military—civil partnership including providing an assistance role in supporting local hospitals, serving independently by setting up field hospitals, or forming a team with civil counterparts. Li et al (2008) described work of the seven emergency medical assistance teams of the second military medical university in the disaster sites. It is important to realise the role of the PLA in major disasters in China, and coordination plans must be made beforehand.
2. Specialised medical training
Training for pre-hospital responders should focus on the initial triage and stabilisation of the injuries commonly encountered. In a retrospective study of field first aid by Haojun et al (2011), the commonest causes of death include severe craniocerebral injury, massive haemorrhagic shock, and crush syndrome causing multiple organ system dysfunction syndrome. The authors call for strengthening the on-site emergency medical resources and equipment for more efficient delivery of field first aid operations.
2a. Field triage
Studies have highlighted various methods of field triage after the Sichuan earthquake including physiologic criteria like the Simple Triage and Rapid Treatment (START) triage recommended by the Ministry of Health (Zhang et al, 2012), and individual hospitals (Jiang et al, 2008) adopted more comprehensive approach which included further steps including anatomic criteria, mechanism of injury criteria and special considerations like age similar to the ‘Guidelines for Field Triage of Injured Patients’ published by the US Centers for Disease Control and Prevention (2008). Standardisation and promotion of a common triage criteria will enhance the coordination of various pre-hospital medical teams and its receiving hospitals.
2b. Orthopaedic injuries
Limb injuries are common encountered in earthquake disasters. Zhang et al (2009) reported most common injuries for adults admitted to hospitals were injuries to the knee, lower leg, ankle and foot (36 %) followed by head injuries (18 %); injuries involving multiple body regions accounted for 10 % of all cases. For children, injuries to the knee, lower leg, ankle and foot were also the most common (19 %), while head injuries and injuries involving multiple body regions both accounted for 13 % each. This highlighted the importance of training on the use of splint, reduction of dislocation, management of open fractures and crush injuries.
2c. Head and spinal injuries
Early recognition of head and spinal injuries are crucial for reducing neurological disabilities. From a study (Jia et al, 2010) looking at the neurosurgical departments in major hospitals in Sichuan, 71 % of the 1 368 patients admitted had minor head injuries. Overall 7.2 % patients received surgery and 2 % of patients died in that study. For spinal injuries, the most common region was the lumbar spine (38.5 %) followed by the thoracic and the cervical spine, with 53.8 % of spinal injuries resulted in neurological disabilities (Chen et al, 2009). Providing training on the proper technique for spinal protection during extrication may reduce the number of patients with neurological disabilities.
2d. Thoracic injuries
In total 10.1 % of the patients transferred to West China Hospital suffered from chest injuries (Hu et al, 2010), 20.7 % developed respiratory failure requiring mechanical ventilation ranging from 3–72 days. Risk factors for respiratory failure included flail chest, pulmonary contusion, and crush syndrome. Furthermore, these statistics are typically under reported, since those with severe thoracic injuries would have died before reaching the hospital. Training on pre-hospital management of thoracic injuries are important as urgent conditions like tension pneumothorax and open pneumothroax will require field intervention before transfer of the patient.
2e. Multiple trauma and crush syndrome
Crush syndrome is also called traumatic rhabdomyolysis where metabolites from muscles are released from prolonged pressure causing shock or renal failure. The stabilisation of victims with multiple trauma or with complications like crush syndrome is much more difficult in the pre-hospital setting, but vital for the survival of the patient in disasters until advanced medical care is available. From the 533 patients transferred for further care in Chongqing, 13.9 % had an injury severity score (Box 1) above 15 (Yang et al, 2009), 6 % of patients required an amputation, while 3.6 % had the complication of crush syndrome and 52.7 % of patients required operations.
In another study, Li et al (2009) described the management of 32 cases of crush injury in a frontline tent intensive care unit. 15.6 % of patients underwent amputation and 53.1 % of cases met the criteria for crush syndrome and received haemodialysis and prompt surgical intervention. Six (18.8 %) patients died, four due to multiple organ dysfunction syndrome and two due to acute renal failure.
Tu et al (2009) also described difficulties in stabilising the rescued survivors in their emergency medical team. They highlighted the deaths of a five-year-old girl with bilateral open fracture of lower limbs and an eighteen year-old-female with bilateral lower limb crush injuries, and further illustrating the importance of recognition and early treatment of sepsis and crush syndrome.
2f. Urban search and rescue medical problems and confined space medicine
Specific medical knowledge to manage these clinical conditions have been described in detail by the US Federal Emergency Management Agency (2010) in their Medical Specialist Training Manual and the guidelines of the INSARAG (2011). These training manuals provide details into what specific medical knowledge is required, especially the common urban search and rescue (USAR) medical problems and confined space medicine.
The emergency care capabilities of the USAR team from the INSARAG (2011) guideline:
3. Psychological preparedness of team
Psychological wellbeing is essential for the functioning of the team. Liu et al (2009) highlighted the psychological problems faced by rescue team members and suggested that 1.94 % of the rescuers may suffer from post traumatic stress disorder (PTSD) as suggested by a PTSD checklist (Box 2). A number of papers (Chang et al, 2008; Li et al, 2009a; Zhang et al, 2011) reported that somatic symptoms were common for Chinese first responders and that social support was a major protective factor. It is important for pre-hospital personnel to be educated about the typical psychological issues they may experience and recommend help seeking behaviour.
4. Application of information technologies
The use of new technologies may help to solve the problems of poor communication and lack of information faced in the Sichuan earthquake. Various technologies have been piloted in many areas of emergency medical services and adapted for disaster situations (Chan, 2004). Communications can now be improved with the use of satellite and third generation wireless networks.
Geolocation and patient tracking using global positioning system (GPS) and radio frequency identification (RFID) techniques may be much easier than using paper maps and tags. RFID tags use radio frequency electromagnetic fields to transfer data for purposes of automatic identification and tracking. Ambulances can now be tracked by GPS to ensure better coordination and response. Electronic dashboards have replaced white boards in many incident commands. Telemedicine and internet surveillance systems can significantly improve linkage between hospitals and the transfer of patient information. Pre-hospital health personnel should be updated with the use of new technologies so that these tools can help in future disaster situations.
5. Management of dead bodies
Although there is a fear that dead bodies will cause epidemics after disasters, it has now clear that this is not the case (ICRC, 2004; Morgan, 2004). Local advice should be followed with respect to forensic requirements for evidence gathering at the scene of any disaster. Commonly observed practices such as rapid mass burials and spraying disinfectants are not supported by scientific evidence. If local forensic guidance allows, dead bodies should be put in bags and placed in cold storage to preserve bodies for identification if at all possible. Proper management of dead bodies can reduce mental distress of survivors and avoid legal problems for relatives of victims.
6. Training in disaster data interpretation and management
Although there has been a significant amount of literature published from disasters in China like the Sichuan earthquake, good quality data on patient outcomes is still lacking. It has been difficult to establish the true statistics on the different injuries and disease patterns following the earthquake, as the figures reported were extracted from different hospitals with different reporting standards and methodologies. The challenge would be for future studies to provide more standardised and comprehensive data on disasters in China under austere circumstances.
Delivering training and understanding its outcome
Currently, many of the pre-hospital emergency training programmes (ALSG, 2002; NAEMT, 2003) supplement conventional lecture based teaching with practical skill stations and table top exercises. Experience from Taiwan (Chi et al, 2001) has shown that table top exercises are superior to field operation exercises in linking the results of disaster exercises to appropriate changes in terms of training, equipment, supplies and plans and also to show the ability of other to fill in during the absence of key officials. Ingrassia (2011) demonstrated the effectiveness using RFID technology in a mass casualty incident simulation. These have all shown the use of different training methodologies to simulate real life disaster situations for better preparedness. Equally important is the monitoring and evaluation procedures to observe the outcomes and the likely impact of the training. Examples can be taken from other well known training courses like the Advanced Trauma Life Support course and the reduction in the mortality from trauma (Ali et al, 1993).
Conclusions
Although the Chinese government received praise for its rapid response (Watts, 2008), education for the pre-hospital personnel was identified as one of the key factors for enhancing its disaster reduction capability. Development of core competencies for training and evaluation methodologies are essential to achieve the outcome intended. Furthermore, the psychological aspect and the management of dead bodies, the use of information technologies and collection of data for review purposes should not be neglected.