Discussion
The lack of communication between our hospital and the field meant that we were totally caught unawares at the onset of the crisis. Our first inkling was in the arrival of the first surge of wounded patients. Normal hospital response to severe trauma begins with trauma team activation following advance notification. This is the ideal in isolated trauma scenarios but is even more imperative in mass casualty scenarios. Communication has been identified as a key component of disaster preparedness and response. An analysis of the response to three sequential aircraft crashes in Texas, found communication to be one of the major problems encountered in the implementation of the community and hospital disaster plan [
5]. Its total absence meant that we were completely unprepared to receive the first surge of casualties and each subsequent surge was without advance warning. Communication was also needed for mobilizing personnel and other resources from within and outside the hospital, and for information and media management as well as the coordination of response efforts between medical personnel and other agencies of government involved in the disaster response such as the police, military, Red Cross, and other voluntary organizations. The lack of this communication made the overall response efforts disjointed and uncoordinated. The crisis took place before the introduction of mobile telephony in our city and we do not have pagers or two way radios. The existing hospital intercom system and the fixed lines proved grossly inadequate for the internal and external communication needs respectively.
Field triage was crude and did not follow any organized systems. Injured patients were merely conveyed to the hospital if they were fortunate enough to chance upon a military patrol, aid workers and volunteers, or other good Samaritans who were willing and able to help. The aim of triage is to identify that minority of critically injured patients, out of the large pool of patients with less severe injuries so that trauma care assets can be prioritized in favor of the former. Effective triage is necessary to screen out the majority of non critically injured survivors, and results are best when performed by a trained physician in the field [
6]. A change in philosophy occurs in the approach to the management of mass casualty: the goal is to do the ‘greatest good for the greatest number’ and not the greatest good for the individual [
2,
7]. Most effective triage systems accept an overtriage rate of up to 50%, i.e. patients who have been triaged as having critical injuries when in fact they had less severe injuries. This high rate is necessary to reduce the undertriage rate to below 0.5%, i.e. the proportion of patients who were triaged as having non critical injuries when in fact they had critical injuries [
7]. In the absence of systematic field triage, a high proportion of patients brought to our facility had non critical injuries as every injured patient was evacuated to the hospital. Higher overtriage rates paradoxically, increase the critical mortality by putting an avoidable strain on the resources needed to manage the critically injured and is therefore undesirable [
8].
The absence of a trauma system in our setting meant that there was no prehospital care. It is therefore reasonable to expect that preventable deaths must have occurred in the field. Chances of survival following injuries depend on how fast the patient can be evacuated to a facility that is able to provide treatment for their injuries.
Movement in the field was hazardous for victims, medical personnel and even the military. For this reason, it was extremely difficult to mobilize staff to the hospital to relieve those that were over-worked; in any case, it was not possible for staff that had been at work for several hours at a stretch to go home for the same reason. Some personnel were on ground for 72 to 96 hours without relief. Evacuation of the casualties was left mainly to security personnel. Non military personnel who carried out rescue did so at great personal risk. Some medical personnel who braved the streets were attacked, and when a 24 hour curfew was imposed on the city and its environs, such attacks were as likely to come from military personnel enforcing the curfew as they were to come from rioting civilians breaking it.
There was a lag in the take off of the hospital response, due to lack of prior warning. Once it started however, it was efficient in the first 24 to 48 hours. Subsequently supplies began to run out with a resultant dip in the standard of care. Intravenous fluids, dressing material, splints, essential drugs, sterile instruments and blood soon ran out. We noted particularly that patients requiring large volumes of blood transfusion for resuscitation in the ER often depleted the blood bank reserves without surviving, in the process putting a huge strain on the availability of the product for those that required it for surgical operations. This explains why some protocols urge that serious consideration be given to avoiding blood transfusion in such situations [
9].
Supplies had been mobilized from other parts of the hospital as the ER reserves ran low, but it was not possible to replenish these sources as they became exhausted. Even when certain supplies were available in the main hospital store, the myriad of challenges made their availability impossible. For example, while the ER and wards had run out of supplies of sterile dressing materials, the main hospital store had enough stock to last 90 days. These were not available however because the head of stores who had access and authority to release them was not on the premises. Communicating with him was a challenge. When contact was established, he could not come because of the violence in his neighborhood. There was a pool of duty vehicles to convey him, but most drivers were not on the premises and couldn’t come in either. When a driver was mobilized, he required security personnel for protection. The mandate, and preoccupation, of the security personnel of course, was maintenance of law and order, not escort. Such was the nature of the largely logistic problems encountered. The food supplies of the hospital were soon depleted too because not only patients had to be fed, but all people taking refuge in the hospital.
Record keeping was haphazard. Some patients had no medical records. Some had but these were incomplete. Personnel who attended to patients with trivial injuries often moved on to other patients without documenting. Only those who went on to have surgery had detailed and accurate documentation of their treatment. Poor record keeping is ubiquitous in the management of mass casualties but accurate record keeping ensures continuity of care, avoids duplication of efforts, and allows a retrospective analysis of the response effort at debriefing [
2,
7]. It is recommended that tags (which may be laminated) should be used for identification and teams trained to use short forms and concise writing in keeping patient records under such situations [
1,
7].
Hospital personnel who were trapped in the hospital for over 72 hours soon began to manifest features of physical and mental stress. Overwork was a major factor, but in addition, there was anxiety for personal safety, fear for the lives of loved ones, and worry over the eventual outcome of the crisis. The sight of severely injured casualties often with grotesque wounds, and the charred, dismembered corpses deposited on the floor outside the morgue (the morgue itself was filled beyond capacity) contributed to the stress. Some people too had narrowly escaped death at the hands of rampaging mobs, prior to finding refuge in the hospital. Acute stress disorders and have been known to accompany the experiencing of such traumatic events and could be a forerunner of Post Traumatic Stress Disorder (PTSD). Although more commonly described among survivors (direct victims) of disasters [
2], it has been found among indirect victims such as first responders and the general public [
10] and the need for disaster plans to incorporate provisions for emotional evaluation and rehabilitation of casualties is increasingly advocated [
2,
7].
The Jos crisis of 2001 was in part a religious one. Tensions flared periodically between Christians and Muslims on the premises, due to the mixed composition of the large numbers of people seeking refuge there. Most people, including personnel invariably found their sentiments swayed to on one side of the divide or the other and the ensuing tension threatened to degenerate into violence. It took the dexterity of top management and senior staff to douse the tensions and focus all efforts on the emergency response while emphasizing the need to maintain neutrality in the hospital. Despite this, rumors that victims identified with a particular section were being discriminated against led to an attempt by some rioters to attack the hospital. The perimeter fence of the hospital was already breached before attack was repelled by military personnel guarding the premises. Work place violence is a well documented phenomenon even in peacetime [
11‐
13]. Whether caused by the strain of the ER environment on the staff, or unmet patient expectations, aggression is ultimately fuelled by perception, intolerance, misunderstanding and loss of control [
12]. Some patient expectations maybe unrealistic in the ER environment and some of it may be caused by the media. In our case some of the perceptions about the crisis were due to rumours, inaccurate information and faulty reportage by the media. Eruption of violence in the hospital would have brought all response efforts to a halt. Such a situation where the hospital is unable to render any meaningful care to casualties, either because it is itself, consumed by the event (such as war, earthquake or nuclear disaster) or because it is overwhelmed by the sheer volume of casualties, has been termed a Major Medical Disaster [
2] and is a situation best prevented.
In the heat of the response, patients who had been transferred to the wards following resuscitation in the ER or operation in the OR often had suboptimal subsequent care. This was because attention was focused on the fresh casualties from the continuing influx in the ER at the expense of those said to have been already “stabilized”. The trickle of personnel who were mobilized from outside the hospital as the crises progressed were directed to the ER and OR, leading to neglect of those in the wards. Some of such patients missed their antibiotics, fluids and wound reviews. Some carried nasogastric tubes and catheters for too long and went for unnecessarily long periods on nil per os. There was near total neglect of patients who were on admission in the wards for other reasons prior to the onset of the crisis. Initial response involved mobilization of personnel from the wards to the ER and this did not begin to reverse till near the end of the crisis, five days later.
A unique, if rare category of patients who suffered suboptimal care during this crisis were patients who, developing a medical emergency at home, were able to get to the hospital. Examples include patients with diabetic crises, hypertensive emergencies and other medical emergencies. The care of the trauma patients was prioritized above these patients even when the injuries were not nearly as life threatening. A major contributory factor was the near total absence of internists as part of the disaster response in the erroneous belief that a mass casualty situation called for the mobilization of only surgeons. Some protocols propose that hospital call-in plans should focus on doctors in the surgical specialties and that the inclusion of internists should only occur as a last resort [
14]. While this is certainly reasonable, we found we had occasional need for the services of internists because of prolonged duration of the disaster and therefore, response. Emergencies arising from the (internal) medical wards, in patients on admission prior to the crisis were also another instance that required the expertise of internists. Institutional response to a mass casualty situation is an effort that involves the entire hospital. Even non medically trained personnel could be utilized for simple interventions for patients with less severe injuries that would allow the experts to concentrate on those with critical injuries. Yasin et al. [
15] found the mobilization of medical students as well as trained and untrained volunteers to be very useful in their response efforts to the mass casualty from the Pakistani earthquake of 2005 and that was our experience. These have to be properly supervised and guided otherwise it could introduce additional chaos that would be detrimental to the response effort [
16].
Competing interests
Te authors declare that they have no competing interests.
Authors’ contributions
KNO was involved in the mass casualty response, debriefings and drafted the manuscript. ICP was involved in the debriefings and conceptualization of the study. SJY was involved in the mass casualty response, debriefings, study design and literature search. AVR was involved in the debriefings and data collection. HCN was involved in the mass casualty response, debriefings and literature search. All authors read and approved the final manuscript.