Written by Samita Giri, PhD candidate at NTNU, the Norwegian University of Science and Technology
This is a story about how a collaborative project between Dhulikhel hospital (DH) in Nepal, the Norwegian University of Science and Technology (NTNU) and St. Olav’s Hospital, University Hospital Trondheim, Norway, showed fruitful and life-saving result during the Nepal earthquake in 2015.
On 25 April 2015, middle of the day at 11:56, I felt a very high intensity shake. I was inside the house with my husband. My husband told me that it is an earthquake and he immediately ran out of the house and asked me to run with him. I was unable to move for a few seconds, I rather tried to hide under the bed instead of running out. I was seven months pregnant expecting our first baby in July. My husband came back to take me out. I could hear people screaming and running to the safest place that they would think of. My family and I was safe and our house was still standing. Within an hour after this first quake, the ambulances, motorbikes, trucks, cars or any kind of transport system that were available started rushing towards the hospital. Some of the victims were even carried by their family members & neighbors with some heavy bleeding. I was living in a few minutes distance from the Dhulikhel Hospital (DH). DH is one of the tertiary level hospital for the Kavrepalanchok district and for few other neighboring districts.
Most of the regular health facilities were closed because of the weekend. My husband decided to go to the hospital the first day. After a while, I received a phone call and it was my supervisor (Prof. Erik Solligård) who was asking if we were safe. I was very happy to hear him. We were outside the whole day. I was very scared to go back to the house and the same feeling was with my family members and my neighbors. We bought some dry foods from the local shops and spend that night in a public bus that was parked in the bus station. We spend our nights outside under the tents and sometimes inside the bus for almost a month after the first earthquake. I started to go to the hospital from the second day to help in the areas that I could. Personally, I also felt more safe being in the hospital and making myself busy. I usually started my work from 8:00 in the morning until 20:00.
I still remember, the second day after the earthquake when I was in the hospital, the number of earthquake injuries escalated in the hospital, all the beds and almost all the space in the courtyard was occupied. The working conditions were continuously demanding. No one was prepared to deal with such a large number of injured patients. This was Nepal’s first experience in responding to a major disaster almost after eight decades and DH had never been the first-line health care provider after an earthquake. However, the hospital was in the process of improving emergency health care through the “Dhulikhel Hospital Patient Care (DHPCARE)” project, a collaborative project initiated in 2013 between DH, the Norwegian University of Science and Technology (NTNU) and St. Olav’s Hospital, University Hospital Trondheim, Norway . The main interventions in this project were the introduction of a systematic emergency registry, a systematic triage system, and simulator training among health personnel in the emergency department (ED). As part of the project, the ED was reorganized to separate patients into three treatment zones (red, orange/yellow, and green) according to four triage categories (red, orange, yellow and green), with separate staff attending each zone since Feb 2015. I was the coordinator from the DH in implementing the project.
DH located in one of the most earthquake-affected districts of Nepal started providing 24 hours health services from day one to the earthquake victims. The hospital set up immediate medical direction, 24-hour surgical services, infection control teams, and logistical management teams, who had a vital role in managing unexpected workloads and providing efficient and quality health care. One of the major task force was the establishment of triage zone at the main entrance of the hospital consisting of medical team and volunteers. We started a systematic screening of patients arriving at the hospital using a simplified triage system, and prioritized patients for effective surgical services. We used color ribbons (red, orange, yellow and green) to distinguish the patient according to the severity and were treated in respective treatment zones. This was evaluated as a useful tool by the staffs at the hospital. I believe this is a great example of teamwork in a local hospital with dedicated staffs working 24 hours prioritizing their profession and humanity rather than their family. On the other hand, collaborations between the two institutions could deliver the quality of health service to the people on right time. At the same time, I was collecting the patient information from the triage zone and the treatment area. I thought this would be useful to report for the future preparedness in similar disasters. I find very challenging to have patients’ information during this emergency phase because the situation was very emotional, hospital had large number of caseloads, and in the first few days the hospital was not able to establish the systematic patient registry system. My two dedicated and hardworking research nurses helped me to accomplish this tremendous work.
DH provided emergency health services to more than 2,000 patients. The caseload was unexpected and was almost five times higher during the first five days than the pre-incident daily average. The majority of injuries were lower limb fractures and over 100 severely injured patients were treated. The proportion of severely injured and in-hospital deaths were relatively low indicating that the most severely injured did not reach the hospital. Most earthquake-affected regions in Nepal were rural and mountainous and there were continuous landslides, which affect transportation and prevent timely access to health facilities. The burden of emergency cases was high before the international field hospitals could be established. The international medical teams need some days after a disaster to initiate their services in the disaster affected areas. Until they arrive, patients are often treated by the poorly developed local health system, and many severely injured likely die prior to receiving medical treatment. Our study result and the local hospital experience underline the importance of developing own consistent and robust local health services capable of managing natural disasters such as an earthquake.
I am a PhD student at the Medical Faculty at NTNU under the supervision of Erik Solligård and Kari Risnes who are the project leaders in the DHECARE project. We had presented the experiences from DH including follow-up of earthquake victims in the article “Impact of 2015 Earthquakes on a local hospital in Nepal: A Prospective Hospital-based Study” in “PLOS ONE”, 2 February 2018.
Samita Giri, NTNU