St. John’s Medical College Gujarat Earthquake Relief Team Report
January-February 2001

Index:
1.	Introduction
2.	Preparation
3.	Field Activities
4.	Debriefing
5.	Identified Needs for the future
6.	Profile of team members
7.	Supplies
8.	Coordination with other groups
9.	Future Plans
10.	Thoughts
11.	Acknowledgements
Introduction:
St. John's has always lead what is well known as the “Bangalore Response” to disasters in the Indian Peninsula since the early 1970s. They have sent teams to the West Bengal War Refugee Camps 1971; Andhra Pradesh Cyclone 1977; Bhopal Gas Tragedy; Bangladesh Cyclone 1991; Latur Khillari Marathwada Earthquake 1993 and, as recent experience will indicate, been proactive in sending 3 medical teams to Orissa in the aftermath of the devastating cyclone in the October-November 1999. Medical personnel (General Physicians, Surgeons, Epidemiologists, Pediatricians, Orthopedicians, Ophthalmologists, Nurses) numbering 32 divided into three teams worked over a period of over one month providing care for people effected in areas of Paradeep, Jagatsinghpur and Ersama areas of Orissa. These teams worked along side various organizations including Service Civil International, Action Aid, Medici sans Frontier, Community Health Cell, and Catholic Hospital Association Of India and even along with the Indian Army. Work included not only medical preventive and curative measures, but more important work of clearing carcasses, chlorinating wells, education, food, clothing and shelter material distribution as well as initiating rehabilitation programs. Each team spent 7-14 days (depending on a field need base) in the field overlapping to ensure a continued intensive cover to areas most in need. It was following these experiences that St. John’s Medical College started the first and only Medical College Disaster Relief and Training Unit in late 2000. It is this Unit that forms the catalyst for encouraging and planning manpower needs for disaster relief teams, as in the present Gujarat scenario. Bangalore as a city has always responded positively especially since the media has brought disasters literality into the living room.

Preparation:
As soon as news reached, a volunteer list was activated and persons selected to form the first team. However, on the 27th January 2001 the Government of Karnataka (Director of Medical Education) requested for assistance in sending surgeons, anesthesiologists and orthopedicians into the field. The St. John’s team was then divided into two, one to proceed with the Government team and one to proceed individually. Financial backing was sought through a friend of St. John’s and Coordinator “Child for Life Fund”, Ms Parveen Sikand. A pharmacy list was activated which was a modified WHO Essential Drug List according to field need information available at that time. To strengthen the team’s non-dependence on local stressed resources, tents, rucksacks, sleeping bags, food and water were also arranged. Oxfam’s Disaster Relief Team Coordinator, Mr. Unnikrishnan, assisted us in locating local contacts willing to guide us into the field. The local contact identified was the Janvikas group, which was part of a coordinated NGO effort called the Janpath Citizen’s Initiative. By the 27th January, volunteers, medical supplies, team logistics, financial commitments and a local network contact were in place. 

Field Activities:
 To fulfill our commitment to our government, our first three volunteers on their request flew on the 28th January 2001. They were to work under the Government of Gujarat’s Relief Commissioner in Government Hospitals in the effected areas. All three, Drs. Sanjay Joseph (Orthopedician), John Marianand (Anesthesiologist) and Bijay Agarwal (Surgery) have completed a hectic ten days in Patan General Hospital. They operated around the clock and lost count of all the plasters and dressing they completed during the stay. During the initial 3-5 days they averaged 20-25 surgeries per day individually and took care of ten wards (Hospital and Tents) allotted to them. They were so conscientious that their services were extended till the 8th February 2001. Now all emergency surgeries have been completed and only elective procedures are pending. The Karnataka team lost only one patient in spite of their busy schedule, which tells of their affectivity in the field.
The main team of the remaining 10 medical personnel from St. John's flew to Ahmedabad on the 29th February. They carried over 1.6 ton of WHO essential medical drugs which included surgical supplies and basic resuscitation equipment based on available field requests for help. They proceeded to the Janpath Citizen’s Initiative control room at the JanVikas offices at Ahmedabad and then into the field. The team was totally independent with tents, sleeping bags and rucksacks as shelter. Food and water for 48-72 hours was also carried in for the team’s survival till base of established. The team made its journey by road to Radhanpur, Rapar, Neelpar and finally Bhachau. They held roadside clinics and also surveyed interior areas to identify areas not visited by anyone. Finally at Bhachau they camped along side the Indian Army Field Hospital and independently manned the Army camp Outpatient, assisted with nursing and medical care of Inpatients and with surgery and anesthesia for procedures. Communication was set up once our own Koramangala 70-year-old resident Mr. Ramachandra, a HAM enthusiast, joined the team after driving the entire distance from Bangalore. The work predominately included trauma related orthopedic problems like fractures, limb and pelvic which needed conservative and operative procedures. Wounds needed dressings and infections had become common. Failure of the provision of temporary shelters has exposed the displaced population especially women and children to the cold and wind causing acute Respiratory illnesses like Pneumonias. Sanitation and unprotected water supply are problems, which in turn has lead to diarrhea in a few cases however this is predicted to rise with the failure of protection of drinking water sources once the packet water supply is stopped. Prior to reaching the Bachau Army Field Hospital, roadside clinics accounted for around 30-50 patients per clinic, which was 1-4 times a day depending upon needs of the local population. At Bachau, a coordinated effort of two clinics and dressing rooms were set up opposite the Field hospital. Here an average of 100 –120 patients were seen with minor trauma, post injury care and health problems secondary to exposure and poor sanitation. The Army Hospital across the road was handed over to the team to run and here 160-190 patients were seen per day. Our Orthopedician, Anesthesiologist and Surgeon were welcome help in the field hospital operation theater were they assisted the team with dressings, reduction of fractures, plaster applications, both casts and slabs, debridement, amputation, disarticulations and minor non trauma procedures. Over the next five days the patients cared for in this area numbered 392. Of these, 125 procedures were performed under General Anesthesia by our team as it worked in tandem with the field hospital. On the 4th February 2001, with number of patients needing help rapidly dwindling and the presence of numerous other teams in the area, the team leader and the team took a decision that they were no longer needed. They were escorted back to Ahmedabad and flown out after a debriefing on the 5th February 2001.
Debriefing:
The team debriefing was vital for the NGO group to plan ahead. This team was a vital field link in determining medical needs in the area. There assessment of the situation, identification of needs and report allowed for decisions based on facts in the field. Medical problems and needs were defined based on above information. Medical needs for the future would be nursing care of posttraumatic injuries, dressings of wounds, detection and management of infections. Exposure related illnesses like Respiratory infections are on the rise needing basic clinical diagnosis and simple antibiotics. Poor sanitation is leading to potential diarrhea though only a couple of patients reported with this illness. Psychosocial problems are to be expected in the future with people loosing family members as well as everything they have ever owned. As a consequence of this trauma, physical and mental, immediate problems of shock, tension, anxiety, panic, relief and disorientation may be seen. This in turn will lead to a disabling post disaster grief, apathy, unresponsiveness, guilt and the post trauma stress disorder. A team from NIMHANS (National Institute of Mental Health and Neurosciences) was already activated and this teams feedback has added to evidence of their need to intervene in the next few weeks. They have left to assess and coordinate these special post trauma problems by training local personnel in dealing with such situations. Malnutrition and other specific nutritional deficiencies may be the future especially for women and children among the displaced population if food supplies/distribution are not streamlined. Rehabilitation may be needed up to a period of three years. In the past week there have been approximately 6000 doctors in the Kutch area alone and volunteers are becoming a burden to an already stretched infrastructure. The need today is not to blindly go in now but to wait till the specific need arises. Medical Supplies are in plenty with excellent neighbors, roads and airport facilities. This too has become a burden with people painstakingly sitting down to make inventories of all supplies. We may have a situation where the mass of volunteers and supplies has actually been detrimental to the progress of disaster relief from rescue to the intermediate phase of temporary shelters, provision of food and drinking water, sanitation apart from medical team support at this stage. In the next few weeks these observations will change and needs may differ. 

Identified needs for the future:
•	Trauma related: Orthopedic and surgical injuries, Infections and wounds, revision               surgeries – nailing, plates, fixators; rehabilitation, disability limitation – physiotherapy, prosthetics.
•	Exposure related (shelter and clothes): Acute Respiratory Infections, Infections
•	Sanitation/drinking water related: Diarrhea, dysentery, and infections
•	Psychosocial consequences: Grief, Depression, guilt, unresponsiveness, reactions
•	Food supplies: Malnutrition, Vitamin and Mineral (e.g. Iron) deficiencies
•	Gender and Child Issues: Health needs, routine and specific

The profiles of the St. John’s Disaster Relief Team personnel are as follows:
1.	Dr. Venkatesh, Professor Biochemistry and High Altitude Medicine Specialist with over twenty years of mountaineering experiences. Team Manager (To set up, protect and establish base camp, communications and a working environment)
2.	Dr. Sanjiv Lewin, Associate Professor Pediatrics and Clinical Ethics and Convenor Disaster Relief and Training Cell with three-disaster relief team experiences of ten years experience. Bangalore Medical Team Coordinator (Team formation, orientation, kitting and motivation apart from field visits to assist in future decisions)
3.	Dr. Anand Alladi, Assistant Professor Pediatric and General Surgery. With six years experience.
4.	Dr. Sanjay, Assistant Professor, Anesthesia. With three years experience.
5.	Nurse Sara Oomen, Senior Staff Orthopedic Nursing Specialist. With three years experience.
6.	Dr. Olympio D'Souza, Lecturer, Emergency Medicine. With two years experience.
7.	Dr. Gerald Vincent, Final year Pediatric Postgraduate. With two years general duty experience.
8.	Dr. Sanjay Joseph, Lecturer, Orthopedics and Emergency Medicine. With four years of specialist experience.
9.	Dr. John Marianand, Lecturer, Anesthesia, with three years of experience.
10.	Dr. Bijay Agarwal, Final year, Surgery. With two years of surgical experience and two years general duty, including experience in Orissa Cyclone Relief.
11.	Dr. George Clarence, Final Year Orthopedic Postgraduate. With two year general duty experience.
12.	Dr. Sr. Annie, Senior House Officer, Emergency Medicine, with two years experience.
13.	Dr. Arema Pereira, Junior Resident, General duty with a year experience.
14.	Dr. Supriya Cardoza, Junior Resident, General duty with a years experience.
15.	Mr. Ramchandra, Communication Expert and HAM operator. With over twenty five years experience.
16.	Ms. Parveen Sikand, Friend of St. John’s, Social Worker, Bangalore Logistics Coordinator.
The team was equipped to assist in handling patients with Orthopedic (Fractures, Trauma, sprains), Surgical (Blunt abdomen, Penetrating injuries, Chest injuries), General Medicine (Infections, critical care, stabilization, resuscitation), Gender issues (Obstetric and Gynecological problems), Pediatric (Child health, prevention and disease), Multi trauma, Procedures major and minor depending on ground realities, existing and incoming infrastructure to name a few.

Supplies:
Based on information from the field, medical supplies were purchased and shifted into the area of need. The list was a modified WHO essential drug list as per International recommendations. In addition surgical material and equipment was also carried into the field to be shared with teams in need. The St. John’s Team primarily utilized the material. While withdrawing from the field, the remainder supplies were distributed. The Indian Armed Forces Field Hospital received residual Anesthesia supplies including drugs and circuits. Tubes, catheters, intravenous accesses, resuscitation equipment, intravenous fluids, intravenous antibiotics, suture and dressing material were also distributed for utilization in the field. Oral and Intravenous antibiotics, fluids, catheters, caps and gloves, intravenous disposables, dressing material, plaster of paris and vaccines (tetanus toxoid) were handed over to our base camp at Janvikas, Ahmedabad, to be utilized by follow up teams. Attached are the lists of items carried into the field.  
Coordination with other groups:
The St John's team worked in coordination with the Disaster Relief and Training Cell at St. John’s Bangalore and the Emergency Disaster Relief Team of Oxfam India Society headed by Dr. Unnikrishnan. It is Dr. Unnikrishnan who will liaise with identified grass root based agencies / NGOs in the area presently chosen are Janpath Citizen’s Initiative. The first team was sponsored by Care Today (India Today family).
Future plans:
The Disaster Relief and Training Cell have on stand by two more teams ready for departure based on actual field needs. Since the assessment team and the coordinator reported the over burdening of existing infrastructure and resources, it has been decided not to send in the additional teams immediately. Depending on future needs and specific requests future teams will be composed and dispatched. The team has all safely returned 9 days after the disaster. A job well done and a contented group of young doctors that they were able to help people in need!

Thoughts:
Dr. T. Venkatesh (Biochemist, High Altitude Mountainer, Team Leader):
“…I always had an urge to go to hostile environment and do something to make other mans life little better. I always wondered why such a great magnitude of human suffering for no mistake by any one. Nature must have had some reason. I immediatly accepted the offer though just fourteen days earlier my dad passed away in Bangalore, I had just finished the last rites though I could not be present when my fathers body was creamated by my younger brother. I had a deep feeling that I had missed some thing important in my life till I assisted in the cremation of several bodies of earthquake victims at Bhachau. Ten of us and 1.6 tons of medicines…
Dr. Sr. Annie (Resident Doctor, Medicine):
“…Very painful sight – complete destruction…every person they met had suffered losses… human and material…yet they continued to reach out to help others…especially the teams of volunteers…Orphan children helped …Githish Bhai and Kunthal Bhen, rescued from the rubble on day 6 spoke about how they survived by drinking urine…afraid and dehydrated with pressure sores…Amidst the destruction and death…Joy and hope with the delivery by caesarian of twins…team work, mutual support and encouragement kept spirits up to work in the field…pleasure to work along side the Armed forces field teams…infected wounds, fractures, amputated limbs, especially in children and the elderly especially painful…frequent after shocks were terrifying, initial non acceptance and inability to begin work immediately, heavy load of supplies, lack of communication all added to the level of anxiety and fright…”
Dr. Anand Alladi (Pediatric Surgeon)
“…Few drops in the ocean of relief…a feeling of being useful in our own special way…satisfaction at a job well done…well appreciated by the armed forces medical teams working along side…a very special experience of being able to help people in need when it most matters…”
Dr. Arema Pereira (Intern Obstetrics, Gynecology):
“…an experience of a life time to be able to help people in need…a feeling of being a good doctor to be able to care and use all our healing gifts when most needed…” 
Dr. Supriya Cardoza (Intern, Medicine)
“…Rather disturbing initially till it numbed the senses…rubble all around, people sobbing, orphan children with no one to call their own, ugly wounds, mass cremations, people still searching among the wreckage for loved ones, the stench of decomposing human remains…most touching was how people at work together irrespective of wealth, caste, creed, colour, race to help each other…a learning experience…”
Ms Sara Oomen (Specialist Orthopedic Nursing Tutor)
“…Seven days but an experience of a life time…death, destruction, suffering…initially most unpleasant…realization of the possibility of the same happening anywhere else and anytime else…comfort, hospitality, care shown by all around was overwhelming inspite of their own suffering and losses…we have done what we can, in our own little ways, in our own small corner…what happens later?…who will be there to help later…to rebuild lives when all is lost…that is the time to once again show that we still care…”
Dr. George Clarence (Orthopedician)
“ …no time to think…reductions of fractures, plasters, dressing wounds, transporting those in need for more help, operating in the field operation theatre…screaming in pain…so much to do…”
Dr. O.P. Sanjay (Anesthesiolgist):
“…the devastation was complete…powerful enough to cripple humanity mentally, physically and emotionally…”
Dr. Olympio D’Souza (Emergency Medicine Physician):
“…good team and mix of all specialities…adequate medicines…amazing that funds, supplies and a team of this nature could be arranged at such short notice…”
Dr. Sanjiv Lewin (Pediatrician, Disaster Relief and Training Unit)
“…We care and so we help…sixty three volunteer names within 27 hours…A friend of St. Johns arranges for financial commitment within eight hours for team support…1.6 tons medical supplies in 5 hours sorted and packed by pharmacy staff…medical students helping with packing…security guards and interns loading…administration sanctioning unconditional loans and permissions…Professors and HAM enthusiastic tracking down team…Janvikas control room assisting 24 hours a day…SPARK the adventure club loaning tents, sleeping bags and rucksacks for team kits…Indian Airlines baggage staff and ground staff most helpful and accommodating…Citizens and corporates helping with finances, supplies, and just being available…a logistic nightmare of  sending a team of thirteen along with 1.6 tons of supplies and enough food and water to last more than a couple of days so as not to be a burden on local resources…a great team effort…encouragement for the future…He shall live because of me!…”

Acknowledgements:
Parveen Sikand, a “Friend of St. John’s” without which we would not be able to help!
Care Today for their commitment!
St. John’s National Academy of Health Sciences for their unconditional support!
All those citizens of Bangalore for encouraging our response!