After the Earthquake – Humanitarian Aid

At 3:30 am on February 27, 2010, Central Chile experienced one of the biggest disasters ever to have befallen our nation. This was an earthquake
measuring 8.8 on the Richter scale and 9 on the Mercalis scale, the second biggest earthquake ever in Chile and the ninth worldwide.
The earthquake covered a distance of between 300 and 500 kilometres and the epicentre was located 3 km north of the Curanipe coast at a
depth of 35 km. The coordinates were: 36°12‘28“S and 2°57‘46“W. (1) (Figure 1 obtained from http://es.wikipedia.org/wiki/Terremoto de Chile de 2010)

The earthquake lasted 2 minutes and 45 seconds, which added to its great magnitude
resulting in a high level of destruction. Around 80% of the Chilean population
is concentrated in the affected areas. Chile being a country with a coastline
running north-south, and the epicentre being located 12.5 km from the coast, a
tsunami was probable. This indeed followed in some locations, about 30 minutes
after the earthquake, with waves said by witnesses to be close to 10 metres high,
and in some locations the water reached up to 200 metres inland from shore.
Unfortunately the national warning systems failed. However, as these events have
occurred repeatedly in our history, many people acted instinctively and managed to
save their lives. In total, this event took the lives of 521 people and left 56 missing (2), (3).
There were roughly 2 million refugees, and damage to property is evaluated at
more than 30 billion dollars (1). Constitución, located in Region VII of
Maule, was one of the cities most devastated by this disaster. Not only was this coastal
city struck by the earthquake, but also by a tsunami in 3 waves, which began half
an hour after the quake and reached more than 8 metres in height. In total there were
172 deaths in this city (2). The Tsunami reached the city and flooded it as shown in the map. (Figure 2, source Hydrographic and Oceanographic Service of Chile)

Straight to the disaster area

Approximately 12 hours after the earthquake,
I was informed that the PAME of the Huamachuco regiment in Putre should
be mobilized to the affected area and would be under my command.
The PAME force was made up of Army personnel from various locations: the
„Huamachuco“ Regiment from Putre, the 2nd „Cazadores“ Armoured Brigade in
Pozo Almonte, the „Coquimbo“ Regiment in La Serena, the „Maipo“ Regiment in Valparaíso
and the Santiago Military Hospital. The material was transferred from Iquique
by air to Santiago, and then by road to Constitución. In 9 hours we reached the
area (2 hours in the air and 7 on the road) and 6 hours later the PAME was already
operational. (Figures 3) A PAME (Puesto de Atención Medica Especializada -Specialized Medical Care Unit) is considered a secondary level of care in combat and is meant to be used for stabilization of injuries, either ready for a return to the line of fire, or for evacuation
to a better-equipped centre such as a field hospital. In this situation it was to be used
for something else, namely to fill the gaps in the regional health network. It is estimated
that 79 hospitals were damaged by the earthquake across the country (1).
In total I served for the first 20 days after the earthquake in that area, but the PAME
is still operational to date in the area and is expected to be withdrawn at the end of this year.

Formation of the PAME for
Constitución

A PAME has modular tents which can be installed and operated according to
the needs of the mission, such as a hospital room, procedure room and operating
room and staff accommodation. It has air conditioning, a water tank of 5000 litres,
electricity from a generator with autonomy for 12 hours, and bathroom annexes
(Ecobath). Our PAME has a capacity of 20 beds (12 for adults, 4 for obstetrics and 4 for paediatrics) (Figure 4) The tents were set up with the following configuration: access tent, nursing procedures and treatment room, operating room, and 2 ward tents (1 for men and one for women and children) The PAME’s Army personnel was made
up of: 2 Health Officers, 1 Logistics Officer, 1 University Nurse, 10 Military Nurses, 10
Stretcher Bearers composed of professional soldiers, 1 electrician and 3 drivers. All the
staff, as mentioned above, came from different garrisons across the country.

Health Situation in Constitución after the earthquake

The biggest health problem was acute infectious diseases and the worsening of
chronic diseases. This, we believe, was due to the living
conditions in which the population was left. Many people were sleeping in tents
and some were huddled in shelters, where hygiene was not controlled at first. Later
on, the Army was placed in charge of veterinary services, and helped to sanitise
these shelters and other places in the city. Another problem was the lack of health
supplies such as drinking water and electricity, which is clearly a risk factor for
acute diseases. On the other hand, in the early stages people did not consult the health network, a result of the fear the people felt regarding fresh shocks in the first days after
the earthquake. It is noteworthy that there were several aftershocks of intensity
greater than 6 on the Richter scale after the quake, many of them leading to the
collapse of damaged structures and to Tsunami alerts that kept the population in a
state of constant vigilance and growing fear. This delay in consultation meant that
patients did not receive their medication in a timely manner and were not examined
for early signs of deterioration. Also, the pharmacies, like the other businesses
in the city, were affected by the quake, both through damage to infrastructure
and by the looting that occurred before the Army arrived in the area.
The triage of the immediate health catastrophe was conducted by health officials
and local firemen. Trauma pathology caused directly by the earthquake could be divided into: lifethreatening trauma (not derivable) and non- life-threatening trauma (derivable).
The first group of trauma was seen in the first 12 to 18 hours post-quake by the regional
health network, Constitución’s hospital playing the leading role in this work.
Non-life-threatening conditions were referred to a better-equipped centre, such
as the Regional Hospital of Talca, within 24 hours. For these shipments it took the
SAMU (System of Emergency Care) 2 hours on the journey from Constitución to Talca.
Conditions resulting directly from the earthquake were chiefly: contusions, exposed
fractures, limb amputations, bleeding, and drowning or asphyxia caused by
the tsunami. Such injuries were sustained mostly by people who could not escape
from their homes, including adults, children and the disabled. In the case of people
who were at that time located on the island at the mouth of the Maule river, the
tsunami had no selection criteria. The earthquake also produced trauma
pathologies as an indirect consequence, that is, as the product of the debris, structural
damage and collapse of houses in the aftershocks. This type of injury was mostly
in closed fractures, penetrating contusions and cuts, bruises and sprains. All of these,
suffered mostly by rescue personnel and the inhabitants of the city during attempts
to recover bodies and items of value, and in the process of reconstructing housing.

Medical conditions treated

The PAME at Constitución did not work as a place to provide treatment directly to
the population. Our mission was to provide supplementary beds and wards for
the local hospital, because it had suffered major structural damage in its wards and
treatment rooms, but the emergency service was still operating, so that patients had
to pass through emergency there before being referred and admitted to the PAME.
Subsequently, the operating room was authorised to handle emergency caesarean
sections, in which it was not possible to wait the two hours necessary for transportation
to Talca. 71 patients were hospitalised in the first 20 days: 39 men and 32 women.
Within this period, 70% of hospitalized patients were discharged and 20%
required transfer to another facility. The average length of hospitalisation per patient
was two days. The above data show that although a PAME is intended as a site
for stabilisation and referral, it can also resolve a large percentage of cases of illness.

Table 1. Hospitalization from day 1 to 20 in the PAME at Constitución

* 12 patients sill remained in hospital

The pathologies of hospitalised patients can be broken down into 4 groups: infection,
deterioration in chronic conditions, injuries and other acute problems such as pancreatitis, gastrointestinal bleeding and ureteral colic.

Chart 1. Pathology Group hospitalized from day 1 to 20. PAME Constitución

The principal infections were those of the respiratory and digestive systems, plus
skin infections associated with poorly maintained surface wounds.
The principal deteriorations in chronic diseases were: metabolic crises in diabetic
patients (hyper- and hypoglycaemia), heart failure and COPD (chronic obstructive
pulmonary disease). The traumas consisted of closed fractures, mainly of the lower limbs and developing TBI.
The average age of hospitalized patients was 53 years and with regard to age distribution,
the great majority were older adults (49%), similarly to all other health centres. The age groups showed no clear trend towards any particular kind of condition treated.

We had 6 paediatric patients hospitalised with an average age of 3 years. The pathology
most often seen in these patients were gastrointestinal infectious processes.
The few outpatient cases were primarily for Army personnel deployed in the area
who required medical attention for conditions such as headaches, cuts and upper
respiratory viruses. During the 20 days I was in charge of the PAME, there were 6 births, of which 2 were by Caesarean section and the other four vaginal deliveries. Caesarean sections were performed by the duty OB/GYN from the Hospital of Constitución, assisted by the
corresponding Health Officer (Figure 6). For births, the PAME treatment room was also equipped with inputs from the Hospital of Constitución, and had a shift of nurses and a midwife 24 hours a day, with a Gynaecologist and Paediatrician also on call. These were all staff from the Hospital of Constitución (Figure 7). The babies born were oddly all female
and there were no incidents, either in C-sections or vaginal deliveries. Nor were
there postpartum problems either for mothers or babies in the days after birth.
The mothers stayed for an average of 2 days in a tent set up for that purpose and
so that their relatives, including the fathers of the newborns, could visit daily.
The logistics of caring for the sick (food, bedding and medical supplies) and also
the human resources were provided by the Hospital of Constitución and this was
achieved through a good communication and transport system between the two
hospitals. We in the PAME had an ambulance and a truck for this purpose.
As for the human resources provided by the hospital, we have already mentioned
the shifts worked by midwives and nursing auxiliaries, but we should also mention a
24-hour shift for nurses and paramedical and technical assistants. Doctors at the
Hospital of Constitución also provided daily visits to inpatients.
Another key point was that the PAME’s direct communication with the SAMU for
patient admissions and transfers from the PAME to the hospitals of Talca and San Javier.
When time permitted it, we were able to make medical rounds to outlying rural
clinics in the city of Constitución, and what we saw was that they were in better
condition after the earthquake when compared with the clinics and hospital of Constitución.

Table 2. Resolution

Conclusions

The experience of all the staff who worked on the PAME is not one likely to be repeated often. Although it was arduous, the rewards of helping our compatriots in need cannot be compared with any peacekeeping mission, and will never be forgotten by our staff.
From the professional point of view, it was a great experience for me and for my
development as a doctor to have been responsible for a hospital in charge, in coordination
with a health network. As an Army officer, it was a valuable experience to have had command of a substantial number of personnel in a national emergency. Of the ailments we treated, we should mention the large number of infections, many of which could be prevented in subsequent disasters by improving postdisaster environmental health at an early stage and ensuring the restoration of basic services as soon as possible. I cannot fail to recognise as a physician, and be proud of it, that in the area of Constitución and other disaster areas, the
health network, despite the damage, was able to provide excellent health care, as was recognised worldwide. The staff of the Hospital of Constitución told us how pleasant it was for them to work in our facilities and with our staff, feeling a sense of security that allowed them to work without fear, despite the constant aftershocks. I think the Army did a great job in providing help in the disaster areas. This is certainly something that will pass into history.
In Constitución the work consisted mainly of providing security against crime, organising the aid received, and rebuilding the city; and as far as I was concerned, in my work as a doctor and commander of the PAME, to provide the best health care possible to all those who needed it at that difficult time.

References
1.- http://earthquake.usgs.gov/earthquakes/eqinthenews/2010/us2010tfan/#summary

2.- http://www.interior.gov.cl/filesapp/Lista fallecidos.pdf

3.- http://www.interior.gov.cl/filesapp/Lista desaparecidos.pdf

Figure 1: Location of the epicentre of the
earthquake and its expansion into nearby
cities. Source Wikipedia.

Figure 2: Flooding of the river Maule and
entry to the city of Constitución as a result of
the tsunami occurring 30 minutes after the
earthquake. Source SHOA

Figure 3: Army personnel assembling the
tents of the PAME in the Municipal Stadium
of Constitución.

Figures 4: PAME tents for hospitalisation for
patients.

Figures 5: Caesarean section performed by
the gynaecologist of the hospital of Constitución
and Dr. Berger.

Figure 6: Photograph of a birth by Caesarean
section

Figure 7: One of the infants in the PAME
receiving immediate care from the paediatrician
of the local hospital.

1. AMBULANCE ENTRY
2. ADMISSION FOR PATIENTS
3. ROOM FOR NURSING PROCEDURES
4. OPERATING ROOM
5. MALE WARD
6. FEMALE WARD
7. PAEDIATRIC WARD
8. PATIENT BATHROOMS

Date: 02/25/2011

Source: MCIF 1/2011