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The 2004 tsunami disaster in Asia – KAMEDO-report 91

The Kamedo-reports are published by the Swedish Disaster Medicine Study Organisation (Kamedo), at the National Board of Health and Welfare. Observers study the medical, psychological, organisational and social aspects of disasters. The results, with a focus on experiences gained, are presented in the reports.


Home transport and emergency care in Sweden

The tsunami disaster of 26 December 2004 indirectly hit Sweden hard. It put extraordinary demands on the Swedish emergency preparedness; preparedness that was not planned for events outside the country’s borders. Thus, for a number of different reasons the measures taken to rescue Swedes involved, above all in Thailand, came to be delayed – which has already been analysed and criticised by the government appointed Tsunami Commission. In contrast, preparations for the reception of those returning from the disaster area were started early by all county councils affected, and cooperation between the authorities involved worked well. Daily telephone conferences between all key players were started the day after the disaster. This facilitated the spread of information and cooperation beyond county council limits, and also resulted in medical teams being sent to Thailand after a few days.

Regarding the transportation home of casualties, it was in the afternoon of 28 December that Västerbotten County Council was given the task of organising medically safe transportation home for the seriously injured. This would take place using the Swedish National Air Medevac (SNAM), which was not fully operational at the time. For this reason it came to be called SNAM light; two MD 80 aircraft with 36 stretcher places each, and an Airbus 340 with 20 stretcher places, were sent to Thailand. The first two flights with the MD 80 aircraft returned to Arlanda airport outside Stockholm on 1 January 2005 after three intermediate stops and almost 24 hours flying time. During the transportation dressings were changed and plasters were reset, but there were no serious medical problems. There were great difficulties involved in sending home manifests and lists of injured people however, which made reception at Arlanda difficult. The transfer of passengers from the ambulance aircraft at Arlanda was time-consuming and complicated, despite ambulance aircraft with more severely injured patients being assigned a special hangar. The management organisation for this transfer did not work satisfactorily. When the patients had finally been transferred to other specially chartered domestic flights, however, transportation proceeded with relatively few complications.

At Arlanda, slightly injured or uninjured passengers who had arrived at the airport with regular flights before the arrival of the SNAM aircraft, had already been taken care of, and this service had worked excellently.

A crisis centre had been established at Arlanda, manned by doctors, nurses, land ambulance personnel, as well as psychological and psychiatric disaster management (PKL) from Stockholm County Council. In addition there were personnel from the Red Cross, the police, the Swedish Church, the social services, travel agents, airlines, insurance companies, the Swedish Civil Aviation Administration, the Foreign Office and personnel from the

Norwegian and Danish embassies. A similar organisation was also established at Landvetter airport, Göteborg. All passengers were registered after the aircraft had landed, and many had their injuries examined and when necessary wounds were re-dressed, and those who needed psychological support were referred to appropriate personnel. There were good resources for onward transportation by ambulance, and therefore there were no unnecessary waiting times for continued land transportation. However, there were certain problems in sending the injured needing medical care in Stockholm to the right hospital since the initial plan was to have a system using rotation of hospitals, irrespective of their resources for offering the specialist care that was necessary. This was dealt with relatively well by the categorisation of injured at the airport, even though some competition arose between the hospitals.

In those counties which had the largest numbers of victims, emergency organisations started their work early. The Stockholm County Council health authorities came to be responsible for taking care of victims from their own area, as well as many of those who were flown to Arlanda airport and who then needed further transportation by ambulance to hospitals in their area of residence. A special reception organisation was created for this purpose at Arlanda. To be able to offer a continuous service of ambulances and medical staff at Arlanda help in the form of ambulance and medical personnel was needed from other county councils. The whole process was made far easier when the Rosersberg rescue centre was opened, which could offer good accommodation and the possibility of rest for ambulance personnel between shifts.

The Västra Götaland region Prehospital and Emergency Medical Centre was to become responsible for coordination of all onward transportation by air and ambulance after the arrival of injured people at airports in Sweden, as well as the reception of uninjured and injured people from the region itself. The work with coordinating all onward flights and ambulances to other parts of Sweden was extensive and demanded a well-established organisation with good contacts with a number of large players including the Swedish Civil Aviation Administration, the Aeronautical Rescue Coordination Centre, the management of SNAM, the National Board of Health and Welfare, airlines and all county councils involved.

The reception of injured and uninjured at Landvetter airport was similar to that in Stockholm. Medical resources at Landvetter consisted of regional emergency doctors, three medical groups (doctors and nurses), ambulance helicopters, psychiatric disaster management groups (15 people) and ambulance resources. An assembly place for injured people was set up in the arrivals hall.

The Skåne County Council health authorities would have the responsibility for the reception of uninjured and injured people in their own region. Also here good medical resources were organised at the airport, even though the number of passengers was considerably fewer. Like the county councils named above, personnel were also recruited who could be sent with medical teams to the disaster area.

Of those who had physical injuries, the majority were treated at different hospitals in the Stockholm region, of which the Karolinska University Hospital in Solna received the most seriously injured. Empty wards were opened, which was important considering the special hygienic procedures that were required. Everyone who had been treated at hospitals in Thailand was initially given their own room when they arrived at the hospital where they could be registered and receive further medical care. Arrangements were made for relatives to be near each other, and to this end an empty department was opened that would function as a hotel.

Cuts and bruises to arms and legs were common and many were badly infected. There were apprehensions of a large number of MRSA infections, but in fact these were fewer than expected. On the other hand there were many wound infections caused by uncommon bacteria or other microorganisms, and in many cases these were difficult to treat, some of them later causing recurrent wound infections. Some of the injured who had major soft tissue injuries needed longer stays in hospital and in some cases advanced plastic surgery to help the healing process. There were no deaths reported during transportation home or afterwards.

Psychosocial problems were overwhelming for many who had lost relatives or family members. Early psychosocial support was offered to every-body when they arrived at airports, as at reception hospitals and/or at the district medical stations that would receive people affected by the disaster.


Home Transportation of Injured and Uninjured

  • If the home transportation of injured people from Thailand had been started earlier, it would certainly have offloaded medical care personnel in the disaster area and would probably have been able to relieve the worries and psychological impact on Swedes affected in the disaster area. Physical injuries, on the other hand, would not have been significantly better treated through earlier care at home in Sweden.
  • In any future disasters abroad, the need to use SNAM must be evaluated early in the process.
  • If it is judged that victims must be evacuated by air and that SNAM is necessary, it is important that the reconnaissance team from SNAM is sent to the disaster area as early as possible.
  • The SNAM representatives who were part of the medical team sent to Thailand played a significant role in coordinating transportation from different hospitals to the airport. Despite this fact, there were problems in coordinating medical transportation from all hospitals with the flight departures available at the time.
  • Plans for how SNAM flights are to be received at airports abroad need to be drawn up. On arrival at an airport abroad, embassy and SAS staff need to be informed in advance. The need for interpreters and guides must be determined, and they must either be on the plane or be in place when it lands. All SNAM personnel must have clothes that resemble uniforms and an ID badge stating their affiliation.
  • It is important that all medical staff are provided with mobile telephones. Every medical team needs to be provided with satellite telephones, and it would be appropriate to train personnel in how to use them. Every team must have a mobile fax.
  • The MD 80 aircraft flight time was long and included three intermediate stops. Their limited range of approximately 3000 km means that other options should be considered, such as the Airbus 340, in the case of longer distances. The SNAM light concept may, however, be developed as a part of SNAM. It has a large capacity and functions well in the transportation of slightly to relatively badly injured patients.

Coordination of Onward Flights and Ambulance Transportation within Scandinavia

  • Obtaining correct manifests from ambulance flights was the greatest problem for the unit (PKMC – Västra Götaland region) charged with coordinating the onward land ambulance or air transportation of tsunami victims within Scandinavia. The manifests arrived late, especially at the beginning of the evacuation, and were not always correct. The reason for this was lack of suitable communication channels from the aircraft. This led to confusion at Arlanda since certain patients were booked on flights and helicopters but could not be found after disembarking. In future, personnel on board aircraft need to be able to transfer information, which is at least partly subject to medical confidentiality, in the form of text and figures.
  • In order to determine which county council and hospital a patient belongs to, access is required to the population register. In similar situations in the future it would be valuable to have access to this information if at all possible.
  • A call-centre that can contact a large number of people quickly has an important function in similar events and must be able to start up activities quickly.
  • PKMC flight coordination and ARCC needed to cooperate better. This would have provided a better grasp of the information, which was extensive and varied and in addition was divided between a large number of lists of arriving or planned flights.
  • Civil aircraft ambulance proved to be very useful for transportation within and outside Sweden. Since there are several players involved, in future the aircraft must be ordered in a correct fashion, for instance only orders by fax by personnel with the requisite authority being allowed as the basis for an order.
  • Cooperation with SOS International in Copenhagen did not work, partly as a result of unclear division of responsibilities, and must be improved. Increased cooperation between SOS International and the authorities involved in Sweden could improve conditions for handling any future crises.
  • The Tp84 Hercules aircraft proved to be very useful for secondary transportation of a large number of injured people. However, its stretcher racks require that military stretchers be used. These stretchers do not fit into Swedish road ambulances, wherefore the injured must be lifted onto other stretchers. In bad weather conditions this must be carried out in a heated hangar.
  • The system of using county council health authorities’ Officials on Call (TiB) for general information, reports on arriving patients, ordering of ambulance transportation from airports and so on worked well. One condition for this, though, is that there is one contact point (portal) for information, preferably in the form of e-mail, which facilitates the spread of information on a large scale. Using only mobile telephones as contact paths, in certain cases exchanging numbers during ongoing measures, is not acceptable.
  • The Stockholm County Council health authorities played a key role in the reception of patients from the disaster area. This is a role which it may be given in the future, since Arlanda is the airport where Swedish national ambulance flights land. The organisation for receiving patients therefore needs to be developed and trained. It is important that direct contacts are established between players responsible for secondary transportation and with somebody from the Centre for Medical Crisis Management or SOS Alarm. This is necessary to avoid what happened: too many players called PKMC to get their own information about passengers on arriving flights.

Initial Care of Tsunami Victims at Arlanda and Landvetter

  • Cooperation between medical personnel onboard SNAM aircraft and the medical management at receiving airports must function well and be trained regularly.
  • The need to take care of patients’ physical injuries at Swedish airports directly after their arrival in Sweden was probably overestimated in connection with the tsunami. Most people with serious injuries had been examined and had received treatment during the flight, and what they needed above all was continued and rapid treatment at a medical institution.
  • On arrival at Arlanda, most passengers had their wounds assessed and re-dressed. It was apparent that a large number of wounds were infected. This delayed the onward transportation of patients and the value of examination is doubtful. Certain injuries were such that patients needed pain relief while they were being re-dressed. The types of bacteria were such that better isolation and cleaning between all re-dressing of wounds would have been appropriate.
  • The medical requirements of each patient must as far as possible dictate where they are sent. This means that certain specialised hospitals will be used more than others. The situation is probably best solved by redirecting other patients instead of using a rotating schedule for hospitals receiving victims.

Care of the Injured at Karolinska University Hospital, Solna

  • Initial care went smoothly after the hospital opened empty wards that were well manned with nurses and doctors and where the injured were immediately given single rooms in which they were registered and given their first treatment. The fact that relatives were able to stay at the hospital was also very much appreciated and probably good support for those who needed continued medical care.
  • The rigorous hygienic procedures that were applied at the hospital from the arrival of the first patients prove to be important, even though the number of MRSA positive bacteria cultures were considerably fewer than expected. However, the bacterial flora proved to include many uncommon bacteria or microorganisms that were resistant to many antibiotics. Despite the fact that on this occasion there was an overestimation of the number of patients having MRSA infected wounds, it is important to consider the risk of serious and unusual infections in similar catastrophes by ensuring that adequate hygienic procedures are followed, among other things.
  • The different types of wounds that were observed were for the most part severely infected. Several different specialists were often required to treat them. Specialist plastic surgery skills were often important for final treatment of the most complicated soft tissue injuries.

The Psychological and Social Reception after Returning Home and the Psychological State of Victims 14 Months after the Catastrophe

  • Only about half of those who received the questionnaire about their psychological state 14 months after the catastrophe actually answered it. This proportion naturally reduces the extent to which results can be generalised and invites caution when drawing conclusions from the results. Of those who did respond, one quarter stated that they still had impaired psychological wellbeing 14 months later. Relatives, friends, colleagues and neighbours most commonly provided support after their return home.
  • The questionnaires showed that victims used many paths to seek help. As shown in other studies, help from relatives was most important, followed by that from friends and colleagues. The support from schools and employers seems to have been great. The public bodies used were primarily crisis groups and family doctors, and counsellors or psychologists at medical centres.
  • Only a small proportion of those who responded to the questionnaire had sought psychiatric help. This may indicate that many received adequate help after returning home, and that there was good knowledge of the effects of traumatisation among care providers in counties and municipalities, in crisis groups and private care providers. With respect to the respondents’ satisfaction with support, among the most commonly mentioned were private psychotherapy, priests, religious groups and insurance companies.
Read the full Summary

Year: 2008
Article number: 2008-123-5
Format: PDF
Pages: 76
Language: Engelska
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Susannah Sigurdsson
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