Dr Gunther Hintz
AT close to 3am on Tuesday, November 23, I received a call about a stampede in Phnom Penh resulting in massive casualties. By that time fairly good television coverage on Cambodian channels showed the Diamond Island bridge cleared of casualties, but continuous arrivals of injured patients at Calmette Hospital.
It was immediately clear that the hospital was severely overburdened with patients. Only the most rudimentary, if any, treatment was rendered to casualties covering the pavements.
In my position as Head of International Medical Development and Public Health at International University, I immediately organised Sen Sok Medical Centre’s excellently equipped ambulances to take patients to the modern facility in Phnom Penh Thmey, dispatched American veteran paramedic Danny Fairbanks with 20 years experience in various international disasters, wars and peacekeeping missions, to the hospital, bridge and other sites to transfer patients to a safe facility.
He was accompanied by SSMC’s ER doctor and an Australian medical student, Rian Crandon.
By 4am the Sen Sok team reported that they were not allowed to touch any patient, no matter how critical, or transfer any, for lack of administrative approval. According to Fairbanks, one of the two physicians present at the hospital would have welcomed his expert assistance.
We cannot comment expertly on the factors leading up to the stampede since our team was not on location at that time. We can, however, comment on the recovery and resuscitation effort since much of it is amply documented with television images and from field reports from our team.
1. A designated overall director with appropriate deputies.
There is no indication that any overall plan was followed. Responsibilities for rescue and triage seemed to pass to whoever felt up to any task with or without any knowledge or skills. None of the uniformed law enforcement officials seemed to be involved in anything more than casual traffic control.
Young civilians seemed to have a free hand at disentangling and transporting casualties in a most haphazard matter, inflicting more serious injuries along the way.
One of the notable exceptions reported by the MC team was a small group of Australian firefighters, well equipped and knowledgeable. We learned later on that this team comes biannually to Phnom Penh to train Cambodian firefighters.
2. A liaison officer to coordinate with other participating facilities.
There seemed to be an absence of any meaningful coordination with the receiving facilities.
3. A communications network.
It is unknown if there was any communication network with the receiving facilities or any other responder. Only Medicorps and its team stayed in contact with Sen Sok Medical Centre and each other via cell phones.
4. An advance team.
No receiving hospital had any advance team on location. This resulted in Calmette Hospital being overloaded quickly and disabled to the point of paralysis.
5. Notification rosters.
6. Triage centre with triage officer.
Apparently, an area of meadow had been cleared close to the bridge to triage casualties. There was, however, no evidence of triage officers in that area. This would have been the ideal stage to save lives by administering respiratory control measures, identify internal and spinal injuries and separating likely fatal cases from recoverable ones. There was no evidence of any such intervention.
7. Personnel assignments.
This is a moot question since none of the necessary network was ever in place on location. It became crucial, and, unfortunately fatal, during subsequent management in the receiving institutions. Holiday skeletal staff were quickly overwhelmed and incapacitated by the sheer number of casualties.
There seems to have been no contingency plan to call on reserve staff to attend to the injured. The Medicorps/Sen Sok team offered on-site assistance at Calmette, welcomed by the physicians in theory, but refused on grounds of lack of administrative authority. Equally, any transfer of patients was refused on the same grounds, even though patients could not receive even the most rudimentary treatment at Calmette.
8. Designation of teams and area of operation.
Only the complete congestion of one institution would motivate ambulances to start dumping patients, dead or alive, to other hospitals. Subsequently, those hospitals would be paralysed by the sheer number of casualties.
It is unknown how many X-rays were taken, diagnostic studies performed and operative procedures conducted to stabilise patients. The number seems to have been inadequate at best.
9. Criteria for categorisation of patients.
Separation of the dead, too severely injured to recover and likely to recover is a crucial process in the management of mass casualties. Here, larger amounts of corpses were ferried by ambulance to the receiving centres than recoverable victims littering the floors next to the near dead and comatose. This failure to categorise undoubtedly led to further avoidable deaths. The separation should have taken place on the disaster site since there was no further danger from ambient causes such as weather, fire, flood or the like.
10. Security arrangements.
Enough uniformed law enforcement personnel were around to assure reasonable security, particularly in view of the absence of any subsequent threat to life and limb. The unfamiliarity of these forces with resuscitation, however, may have contributed to the problems of disentanglement and transportation injuries unknowingly inflicted by civilians.
This disaster serves as a stark example of the consequences of a lack of a mass casualty plan. Medicorps was concerned for years that such a situation would lead to unnecessary loss of life in Cambodia. MC’s efforts to train key Cambodian personnel went for naught, perhaps because of complacency or perhaps because of a lack of will.
In the end, Cambodian authorities, particularly the Ministry of Health, has to assume responsibility for the management of disasters with mass casualties. On the Diamond Island bridge literally everything that could go wrong did go wrong. Tragically, many people lost their lives unnecessarily.
Dr Gunther Hintz is President of Medicorps and an expert in disaster management.