EMS Responder Pakistan 2006

By RubenF
IVYCmedics respond
:''.*9.,.4
;
hen the Kashmirearthquakestruck
nearlya year after a long succession
of disasters
at home and abroad(Asian
tsunami,HurricaneKatrina,etc.)it wasjust one disaster
too many.And this one was too far away,too remote,
with no tall buildings,
no tourists,no compelling
video.
But our group of paramedicsand doctorswonderedif
we coulddo something
to help.One phonecallled to
another.
t":
J
A
coordinatolsays,"We haveneverhad this kind of logistical nightmare,ever.We thought the tsunamiwas the
worstwe couldget. Thisis worse."
Entire mountainsdisappeared,
sliding down and
comingto reston the floorsof valleys,wipingout roads
and telephonelines.In the first days after the earth- ?:.
f:
quake, severethunderstormsand hailstormspounded a,
the region,groundinghelicopterflightsand, for the
thousandsburied alive,wiping out hope that rescuers F
couldreachthem.Forthe nextthreeweeks,nearly1,000
t;
BACKGROUND
aftershocks-manyof them large earthquakesin their rt
For50 millionyears,inchby inch,the Indiansubconti- own right-continuedto jolt the area.Bythat time,how- g
4
nenthaspushedup against
the Eurasian
plate,launching everithere was nothingleft to destroy.More than 80%
;
jagged
the
Himalayas
abovethe mountingtension.On
of all structures
in Kashmirwerecompletelydemolisneo,
T
the morningof Saturday,
October8, 2005,most people
approximately
90,000peopledied,and closeto foturmilwerehome,nappingafterthe pre-dawnRamadanmeal,
lionwereleftwithoutshelterfor the brutalwinter.
restingfor anothei day o{ work and fasting.Then the
In the initialaftermathof the earthquake,separate
weight of the earthslammeddown and the mountains groups led the local response.The Pakistanmilitary
crashed.
The 7.6-magnitude
earthquake
claimedlivesin
heroically
pulleditselffromthe rubbleto savehunoreos,
threecountries.Most of the devastation
occurredin the
while,at the sametime,Muslimextremist
groupsquickly
areaclosestto the epicenterin the city of Muzaffaraoao, raisedtheir flags under which they set up makeshlft
in Pakistan-administered
Kashmir.
sheltersand clinics.The governmentallowedthem
In a land of toweringmountainssheltering
slender and other volunteersto cont;nueuntil humanitarian
forestvalleys,Kashmirwasalreadyone of the most inacgroupscould replacethem. While large,slow-moving
cessibleplaceson earth. Divided between India and
international
agencieslikethe International
Committee
Pakistan
in two warsalonga contesteddissectionknown
of the Red Crossdispatchedtheir assessment
teams,
as the Line of Control,the earthquakeroughenedthe
othergroupswerealreadydeliveringreliefsuppliesfrom
landscape
further.
pre-stocked
warehouses.
The UnitedStatessenthelicopJan Egeland,the United Nations'emergencyrelief
ters and troops engagedin antitenorismmaneuversin
I
I
I
began to obtain enough supplies
to deploy as a self-sustained
unit.
Generousdonationsin kind orovided us with enoughfood, water
and shelter to be indeoendent
overseas.Finally,the World Health
Organization(WHO) coordinators
on the ground in Pakistan
directed
our team to deploy to the town
of Ghari Dupatta, approximately
25 km southeastof Muzaffarabad.
where we'd provide forwardtriage
for the thousandsof patientscoming to the newly establishedfield
hospital.A couple of days after
the earthquake,
we had everything
exceptplanetickets.
It wasn't until two weeks later
that a United Kingdom-based
NGO, lslamicRelief,offeredto pay
for our flight and provide us a
satellitephone. When we arrived
in lslamabad,we discoveredthat,
Photos
byphilSuarez
whileour luggagehad arrived,our
Afghanistan.In lessthan 24 hours, tions between agencies'headquar- cargo was lost, despite our best
searchand rescue,aswellas medical ters and operativesin the field.The
efforts to prevent that from occurteamsfrom aroundthe world, landNational
Response
Planhadonlyone
ring.Airportpersonnelwereworking
ed in lslamabad.No agencywasted
absolute:maximumflexibilityfor the
overtimeor volunteering,and ours
time wrestlingfor command.In the
greatestpositiveimpact.
wasn't the only lost humanitarian
flrstfew days,savinglivescamefirst,
Despite the well-orchestrated cargo. lslamicReliefsent vans and
no matterwho wasin charqe.
response,inadequatefunding condrivers.but no officialsand no satStakeholders
in the Pakistan
relief
demned the reliefeffort.The interellite phone. Our contacts in the
effort created a structurethat maxinational response to the United
governmentwere unable to make
mized collaborationbetween the
Nations'flash
appealof roughly$550
progressin the chaoticcargo offices.
federalgovernmentandthe humani- millionfell embanassingly
short.Ten
We waited in the hot cargo docks
tarian community.PresidentPervez days after the SoutheastAsian tsusurroundedby tens of thousandsof
Musharraf
appointeda FederalRelief nami, 80% of the money needed
reliefboxes,noneof them ours.
Commission,but coordinationwas
had beendonated;10 daysafterthe
A few hours of telephonecalls
never unilateral.The Commission, earthquake,barely 12o/"had been
later,the UnitedStatesArmy agreed
in collaboration
with the more than
received.
to provideus with waterand meals200 United Nations agenciesand
ready-to-eat(MREs)to last us a few
hundredsof NGOs, drafted a bold
HALFWAYAROUND
days until our cargo arrived.They
National Response Plan, which
THEWORLD
offereda helicoptertoGhariDupatta,
organized10 "clusters."The clusIn the hoursfollowingthe Kashmir so long as we were on it within 10
terswerenot intendedto commano
earthquake,dozensof doctorsand
minutes.lslamicRelief,which had a
NGOefforts,but rathertoencourage paramedics
begancallingeachother,
baseof operationsin GhariDupatta.
and set standardsfor facilitatingreswonderinghow they could help. A
said they would provide us shelter
le, reliefand reconstruction.
Each
coreof providersemergedandspent
and a satellitephonewhenwe landtrusterwas co-chairedby the interthe followingdayspersistently
glued
ed. One memberof our teamstayed
"ational huminitarianagency and
to phones,speakingwith humani- behindin lslamabad
to makecertain
:te Pakistanigovernmentministry tarian agenciesfrom New York to
our cargofollowedus.
Fst suited to carryout the cluster's Geneva.They all insisteda team
We managedto convincesoldiers
-andate. Gatheringall agencies like ours was desperatelyneeded,
at the Air Forcebasethat they either
rd groups working in a specific but they were too ovewhelmedto
had to breakthe rulesand allowour
ied, the clustersaimed to share
make decisions.At the same time.
vans onto the tarmac,or we were
r:crmation, prevent duplicationof
the team of 10 paramedics
and two
going to run acrossit carryingall our
=-ic.tsand strenqthencommunica- doctors, many who'd never met,
suppliesto the waitingU.S.helicopwww.emsresponder.com
I EMSI FEBRUARY
TOOU
![
ter. Fortyminuteslater,we touched
down in a smalllandingzonein the
middle of what appearedto be an
improvisedmilitarytent camp,which
the helicopterpilot said was Ghari
Dupatta.He waswrong.
We had landedin Sawan,a small
militaryoutpostin the Jhelum River
valley. A PakistanArmy colonel
explainedto us that Sawanhad been
unreachable
by roadsincethe earthquake, being located far beyond
severalcolossallandslidesthat had
barredaccess
to the largerreliefagencies.GhariDupattawasseveralhours
on foot behind us. Furtherto the
southeast,
almostno aid had arrived.
People carried patients on heavy,
improvisedlittersthroughdangerous
mountain switchbacksto reach the
closestmedicalattentionhoursaway
at a clinicin Sawanbeing run by a
smallmedicalteam of Afghanimilitarydoctorswho were,coincidentally,
leavingthe nextday.No replacement
team had beenscheduled.
During the first days after the
earthquake,
the Afghanssawseveral
hundredpatientsdailyand had performed hundredsof fracturereductions and amputations.The daily
patientcountand severityindexhad
sincedecreased,but it was difficult
to learn how much. Likelyfearing
that tellingus a numbereithertoo
high or too low would mean we'd
refuse to stay, the Afghanis were
hesitantto reveal speciflcs.As far
as medicalsupplies,the clinic-four
beds,somechairsand strewnrubble
underneatha tarp next to a semidemolishedclinic-whileterriblydisorganized,was sufficientlystocked
for severaldays.
We had no means of communicationand no means of getting
out. We had tents and suppliesfor
threeor four days.Our principalconcern was that we were in the wrong
place-potentiallya placewherewe
Day 20 post-earthquake,a
young girl with a shattered
wrist exhibits gangreneto
the hand. Photos
by philSuarez
were either not needed or were incapable of providing the necessary
level of care.
The next morning, patientspoured
in. As the Afghani team helped carry
a patient with a spinal injury to the
landing zone on an improvised
stretcher-a door from a collapsed
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FEBRUARY
2006I EMSI wvvw.emsresponder.com
KHPSO
Haltlrcm
Provtden Senice Orgeiatlm-
Medicstend to patients.
-,:-e--we saw a sign along the road
:-=: r^re'd missed the night before,
n- sr declared: "Warningl Journey
=-ead prohibited for foreigners!"
--: Afghanis thanked us for com-: and took off, leavingthe clinicat
Sa,',anin our hands.
-hree team members
trekked
:a:< for hours to the closest town
r,: a satellite phone to let the
= ei effort know where we were
and that more help was
needed.One agencytold
uswe weretoo far fromthe
epicenterand therewould
be no patients to treat.
But as word spread,our
patientload doubled.The
most seriouslywounded
had been evacuatedon
foot or had died already;
left were the patientswho
had been too sick or nor
yet sickenough.
Our missionhad changed,and
we changedour attitudesto meet
the situation's
demands.We cleaned
up and organizedthe clinic,creating
a fast-trackarea.a wound-carearea
and a resuscitation
area. We also
createda female-only
sectionstaffed
by women,but maleprovidersnever
encounteredproblems in treating
females.Three team members,as
well as the Pakistan
Army'sofficers,
spokefluentUrduand taughtus how
to ask basicquestions.We learned
the capabilities
of differenthospitals
wherewe couldevacuatepatientsby
air. The two-and-a-ha
lf doctors---one
pediatrician,one wound-carespecialist and a paramedicwho was
finishinga physician's
assistantprogram-trained the paramedicsto
carefor wounds.
Althoughmanypatientshad horriblyinfectedwounds,theirswerenot
the only medicalproblems.Patients
with grosslyangulatedclosedfractures, who had received no care
sincethe earthquake,
werecommon.
Acute traumaticinjurieswere also
numerousas patientsslipped and
fell in the shifting,treacherousterrain.We stabilizedthe most critical
patients-from severelydehydrated
babies and traumaticbrain injuries
to wounds so infected that only
hospitals
in lslamabad
couldhandle
them-and then we prayed for a
helicopter.A great number of our
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patientswere sufferingfrom pneumonia,upper respiratory infections,
dysenteryparasitesor scabies.patients
comingfrom milesaheadspokeof no water;no medicine, no shelterand hundredsof people too weak to
climbdown.
Despitethe strongaftershocks,
we sent a four-man
team with an army escortto trek to a town furtherup
the mountains.
Thetown, locatedat the pointof convergenceof threevalleys,had enormousmedicalneedand
1st field hospital where NYC
medics took over from an
Afghan Army medicalteam in
Sawan.
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wasa perfectplaceto set up a second
clinic.Although we'd agreed earlier
not to splitup, we recognized
that the
immediateneedto moveforuyard
had
to be balancedagainstthe need to
continueprovidingcarein Sawan.Half
of our team continuedfonrtrard,
where
they would set up at an artillerybase
locatedonlya few kilometers
fromthe
Lineof Control.They loadedPakistan
Army muleswith enoughmedicalsuppliesfor a few days.We prayedfor our
cargo,whichstillhad not arrived,and
for morehelp.
Our only contactwith the rest of
Pakistanwas a shakyfield telephone
linethat we sharedat night with dozens of soldierstrying to call home.
We used what preciousminuteswe
had to try and securemore help for
our region.Only hoursafterour team
membersleft,a landslideknockedout
the telephoneline aheadof us, preventingour splitteamfromcommunicatingwith eachotherfordays.Finally,
our efforts began to pay off. Two
doctorsand four nursesvolunteerino
from the UnitedKingdomwere flowi
in. The road had opened, and two
nursesfrom DoctorsWithout Borders
arrivedwith supplies.Minuteslater,a
crew from CBS'S60 Minutes arrived
(whowouldeventually
profilethe work
of the NYCmedicson the show)with
camerasand a satellitephone. We
finallycalledour families.
On the last
helicopter;the final member of our
team arrived,alongwith our hundreds
of poundsof suppliesand medicine.
The next morning,the telephone
betweenour two campswas restored,
and we learnedthat the forwarocamo
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:'eating nearly a dozen patientswho would die within hours.
,'/ith the satellitephone, we alerted the militaryin lslamabad
:i the situation. Before noon that day, helicopters flew in to
avacuatethose patients.
As we hiked away from Sawan into the mountains, we saw
:nat someonehad painted,in English,the message'WelCome'
on a pile of rubble. With the team all together and a satellite
ohone in hand, we advocated for the tens of thousands of
people who'd been forgotten. In the following days, more
helicopters flew overhead toward the forgotten valleys. Two
field hospitalssprang up, and we were asked to identi{yvillages
wheresmallmedicalteams likeours could deploy.Massiverelief
drops were occurring ahead. On the roads,we saw many of the
patients we had seen only days earlier;coming back for followup care.The wounds were healing,but our time in Kashmirwas
runnrngout.
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The day before we left, we heard that the villagesin front
of us had been taken care of and we could go home happy
with our job. But as we waded toward the landing zone
through the maze of ruined houses, through the scent of
death and incense burned to hide it, through the wreckage
and the staresof children,through the smilesand gifts of the
people we'd helped, in the face of such annihilation,it was
bard to feel good about leaving.
LESSONS
LEARNED
Our team did many things wrong and many things right.We
learned four key lessonsfrom both.
1. Communicationis a criticalfaclor during a disaster.Not
surprisingly,
standardforms of communicationfail. They failed
on September11,2001, and they failed us in Pakistan.
2. Informationneeds to flow along well-establishedpathways-from small units that can see specific details to the person or persons in the best position to see the bigger picture.
/y'henthis doesn't happen,wrong decisionsare made and the
reediest areas are forgotten. The neediest were lorgotten in
\ew Orleansand almostforgotten in Pakistan.
3. The first moments after massivedisastersare too precious
:c waste.lf there'sno pre-existingplan,or it'sclearthata planwill
tail, everyoneinvolvedneeds
to communicate,coordinateand
:'eate a realisticplan basedon the immediatelyidentifiedneeds
:^d the immediatelyavailableresources.
4. An attitude of flexibility, creativity and collaboration is
:-e singlemost criticalfactor for success.Ego and blame have
-: role in relief.Unfortunately,
when things fall apart, blaming
::'neone or somethingis easierthan getting tasksdone. r
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