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Introduction |
At 2340 on Wednesday, 30 July 1997, a landslide hit the ski resort
village of Thredbo, in New South Wales. Two ski lodges were destroyed,
with the loss of 18 lives. There was only one survivor, rescued about 66
hours after the disaster struck.
More than 30 doctors were directly involved in the rescue effort and
many more covered for their absent colleagues. The NSW Ambulance
Service responded with 183 officers, and hundreds of fire brigade
personnel, police, State Emergency Service and volunteer rescue
association personnel participated in the rescue effort.
Here is a brief account taken from the "doctors' log", a medical record
compiled at the site by the attending physicians during the first few
days of the disaster. Entries were made in the log every few hours to
assist in monitoring the medical progress of the disaster and to serve
as a record for later audit.
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Wednesday
30 July |
2340: Disaster strikes
A landslide completely destroys two ski lodges within a matter of
seconds. Fortunately, the first lodge has only one occupant (as it is
midweek and snowfalls are light), but, tragically, the second lodge
is the staff accommodation for the resort employees and as many as 20 to
30 people are feared trapped or dead. As local rescuers arrive on the
scene, there are reports of cries for help from people trapped within
the wreckage. A rapid assessment of the site by the Thredbo fire
brigade and police reveals that it is dangerously unstable and there
is a strong smell of gas and diesel fuel. The police decide to clear the
site until it is declared safe enough to allow further rescue
attempts.
Two general practitioners who practise in Thredbo and several other
doctors holidaying there are on stand-by at the disaster site, but are
unable to get to people trapped within the wreckage.
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Thursday
31 July | 0030: Medical support is mobilised
A regional disaster is declared (see Box below). Goulburn (in southern NSW,
approximately 300 km from Thredbo) is established as the regional
disaster coordination centre, but as it is feared that regional
resources may be overwhelmed Sydney coordination is also notified.
Teams of doctors and nurses are sent from Cooma to Thredbo and from
Canberra to Jindabyne (a triage point), and a four-person specialist
medical team (an emergency physician, surgeon, anaesthetist and a
medical retrieval specialist) is flown to Thredbo from St George
Hospital in south-eastern Sydney. (Medical retrieval specialists
in NSW are either emergency physicians or anaesthetists who work for
the medical retrieval unit at St George Hospital.) The medical
specialist team is sent from Sydney so as not to drain the supply of
medical specialists from local areas, including Canberra. At this
point, it was feared that there would be mass casualties that would
need to be transferred to regional hospitals. The medical retrieval
unit conducts a disaster bed count and locates 25 potential intensive
care beds in the State.
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| The Thredbo landslide: a regional disaster
A "disaster" is an event that overwhelms the capacity of the local resources to deal with the situation. The level of the disaster is graded according to the size of the response necessary. A disaster may involve mobilising only the resources of a single institution such as a hospital, or it may extend to involve the region, the State or the entire nation. The Thredbo landslide was classified as a regional disaster, although it did extend to involve many resources drawn from throughout New South Wales.
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0730: Forward medical command post established
The medical command post, along with the other emergency
services, is set up in a lodge 50 m from the disaster site. The forward
medical command post is responsible for coordinating the on-site
medical rescue and liaising with medical command posts in Goulburn
and Sydney. Telephone and fax lines, desks, chairs,
stationery and white boards are organised. After consultation with
the fire brigade, it is decided that the police will take overall
charge of the site and coordinate all emergency personnel.
The medical team from St George Hospital relieves the Thredbo and
Cooma doctors, who have manned the site overnight. Their initial task
is to establish a line of communication with both Goulburn and Sydney
coordination centres. The Thredbo medical centre is chosen as the
primary casualty treatment area because it already has the
infrastructure and equipment (e.g., lighting, heating,
handbasins, x-ray machines, oxygen, suction) necessary to
stabilise patients before transport. A comprehensive inventory is
taken of all the medical equipment and is sent to Sydney and Goulburn to
help with planning of additional supplies. A temporary mortuary is
set up in the Thredbo fire brigade station as it is close to both the
disaster site and the medical centre.
People are evacuated from homes adjacent to the landslide as there is
real concern that these buildings may also slip, and also so as not to
hamper the rescue. Arrangements are made for the medical team to
review all evacuees to ensure that they have no special medical
requirements.
A second specialist medical team from Sydney is activated (from the
Royal North Shore Hospital) and accommodation is organised for the
medical staff in Thredbo.
1030: Medical team inspects the disaster site
By mid morning, the initial tasks involved in establishing the
disaster medical command are complete. Geological engineers and
mine rescue experts examine the disaster site and consider it very
unstable. The first inspection of the site by a medical officer is
carried out. The medical team realise that they need to be prepared to
treat possible mass casualties among the rescue workers, and
identify several occupational health issues:
- Irritated eyes/throat. Rescuers to wear goggles and face masks while
clearing dusty plasterboard and fibreglass insulation bats.
- Minor injuries, such as foreign bodies in the eye and
lacerations. Medical supplies are organised from Goulburn.
- Exhaustion and hypothermia among the rescuers. All
rescue personnel are alerted to the relevant signs and symptoms and
told to report any concerns to their superiors and the medical staff.
The medical team decides to inspect the disaster site every four to six
hours to deal with these problems and others as they develop.
Rescue shifts are limited to between four and eight hours, with
adequate breaks during the shift for food and drink. The Salvation
Army provides hot food and drinks around the clock and the rescuers
warm themselves by fires burning in 44-gallon drums around the site.
1620: The first body is recovered
As the bodies of victims are found, the medical team works with
the police disaster victim identification squad. The medical
officers pronounce the person deceased and tag them with a
preliminary identification number. The police take video
recordings and photographs of the victims both at the spot where they
are found and at the temporary mortuary. This information will be
submitted to the coronial investigation into the disaster. Finally,
bodies are taken to Sydney for further examination and formal
identification.
After consultation with coronial medical officers, the police
insist that no bodies are to be viewed at the scene by significant
others. The coronial medical officers state that viewing the body in
this setting can be more traumatic and that identification at this
point is frequently wrong, leading to more confusion, delays and
further trauma.
1830: Second medical specialist team arrives
The St George doctors are relieved by the Royal North Shore team
and are exhausted as they have not slept in 36 hours. The temperature in
Thredbo drops to -14oC overnight.
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Friday
1 August | 0800: St George medical team return to Sydney
It is decided that two medical teams are not necessary at the forward
command post as the medical personnel at both Cooma and Canberra can be
mobilised at short notice. Each medical team at the forward command
post will be replaced every 24 hours by a new team from Sydney. At the
forward command post, teams will divide into two groups of two and work
six-hour shifts to provide 24-hour cover.
The NSW Premier and the Police Commissioner are to visit the disaster
site, and the medical commander is asked to attend a briefing and site
inspection with them.
Several public health and environmental issues arise during the day:
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Water and sewerage is cut off to the site and surrounding
village. Some rescue personnel are staying in lodges without
running water, and toilets are not flushing. One rescue worker
develops abdominal pain, vomiting and diarrhoea. As there is concern
about the possible cause as well as contamination of other rescuers,
the patient is interviewed and returned to Sydney. Water, vomitus and
stool samples are sent to Sydney. A directive is issued to drink only
bottled water or cooled boiled water.
- Exposure by the rescue workers to decomposing bodies and
body effluent. The principles of universal precautions are
re-emphasised to the rescuers, decontamination posts are
established at all exit points from the disaster site, and protective
suits are brought in for those in direct contact with bodies.
- Diesel fuel seeps continuously into Thredbo creek. The leak is largely contained by the fire brigade using booms and
siphons, but some oil escapes downstream. The Public Health Office,
Environmental Protection Agency and Snowy Mountains Shire are all
notified and asked to review the situation.
1500: Meeting the relatives
The doctors meet the relatives of those still missing. The
relatives, understandably distraught and angry that the rescue
effort appears to be going so slowly, interpret the cautious pace of
the rescue as indicating that the medical team has lost all hope of
finding any survivors. The meetings are very emotional and extremely
draining on the already tired doctors.
1800: The third night begins
The rescue effort will continue through the night. Special
helium balloons containing a light source are suspended over the
rescue area to provide a very bright light with minimal shadowing.
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Saturday
2 August |
0530: A possible survivor is located.
The medical team is notified by the ambulance paramedics at the site
that a survivor has been found. The patient is believed to be a male with
minimal injuries. The initial action is to ensure that the relatives
are given the known facts about the survivor before possibly
misleading media reports filter through to them. A rescue helicopter
is activated from Sydney and is to stand-by in Thredbo ready to
transfer the patient to a tertiary hospital.
The information from the site is that the survivor is trapped in a
confined space surrounded by concrete slabs and underneath two
further slabs. The only access to him is through a small hole and it is
estimated that extrication will take eight to 12 hours. Attempting
intravenous access is not feasible, but an oxygen mask is passed down
to him by paramedics. The medical team discusses the clinical
problems likely to be affecting the survivor: dehydration,
hypothermia, rhabdomyolysis and possibly vascular instability if
he is moved or sat up.
A doctor goes down to the site and crawls under the concrete slabs to
assess the patient as best he can. He can only talk to him and see his hand
reaching up through the hole, but cannot reach it. As extrication will
take some time and he appears in relatively good health (from his own
reports), it is decided a trial of warm oral fluids should be tried.
Glucose 25 g is added to normal saline 1000 mL, and the fluid warmed with
a small Biegler fluid warmer (ATOM, Austria) plugged into a
fire brigade power supply. A giving set is lowered to him through the
hole and he sips 20 mL every 20 minutes to see if he can tolerate it.
Surprisingly, he states that the warm saline tastes fine and even
"compliments the chef".
A Warm Touch air warmer (Mallinckrodt, USA) is modified by connecting
a domestic vacuum cleaner hose to the outlet pipe in order to extend its
length. The hosing is insulated by wrapping multiple foil sheets
around the tubing. The warmer is plugged into the power source at the
site and generates a steady flow of slightly warm air through the end of
the long hose. The hose is fed down to the patient, who uses the warm air
to dry his soaking wet jumper and shorts. During this time, a
lengthened pulse oximeter probe from a Criticare oximeter
(Criticare Systems, Inc., Waukesha, Wisconsin, USA) is applied by
the patient to monitor pulse rate and oxygen saturation.
1700: The survivor is rescued
The access hole to the patient is enlarged significantly. An
ambulance paramedic goes down inside the hole with the patient and a
doctor leans into it to perform a saphenous-vein cutdown by
torchlight to establish intravenous access. Two litres of warmed
Hartmann's solution to which has been added 100 mEq of sodium
bicarbonate is infused. A cardiac rhythm strip shows slow atrial
fibrillation, but there are no QRS, ST or T-wave changes to suggest
hyperkalaemia.
The patient is slowly removed from the hole and all efforts are made to
maintain him in a horizontal position, as prolonged hypothermia and
immobilisation might impair his ability to autoregulate his blood
pressure, and sudden movements might cause his blood pressure to fall
precipitately. He is taken to the Thredbo medical centre, where a
"trauma team" conducts a primary survey (airway, breathing,
circulation) and secondary survey (full head-to-toe examination) and initial resuscitation before transferring him by
helicopter to Canberra 50 minutes later. Amazingly, he has minimal
injuries other than extensive frostbite to both feet. A relief
medical team arrives from Westmead Hospital, in Sydney, and, after
aiding with resucitation, proceed to the forward command post and
disaster site. More specialists arrive from the Prince of Wales
Hospital and St Vincent's Hospital in Sydney.
Victim identification, monitoring of occupational health and
public health problems and general medical cover continue for
another three days. Tragically, no other survivors are found.
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Postscript |
From a medical perspective, the Thredbo disaster was unusual in that
there were no mass casualties. However, there was a considerable
workload for the doctors, who, in addition to carrying out medical
duties, had to cope with exhaustion, certifications of death and
dealing with grieving relatives, as well as exposing themselves to
danger while attending to a patient who was still trapped.
The biggest stressor was probably the environment itself. At night
the disaster site was lit with floodlights and helium light balloons.
Anyone approaching the site had to pass through two checkpoints. The
first, "perimeter", checkpoint was manned by the State Emergency
Service, and the second, "central", checkpoint was manned by the
police. At each checkpoint (and at other positions around the site),
fires burned in 44-gallon drums for the rescuers to warm themselves
by. The lights, the fires, the checkpoints and the devastation of the
hillside created an atmosphere similar to a war zone. One medical
officer commented: "It's like being in a Mad Max movie!".
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Acknowledgements |
On behalf of the medical team that attended the disaster site,
acknowledgement should be given to the leadership shown by Dr Ronald
Manning (Emergency Physician). Credit should also be given to those
who "held the fort" while their colleagues were in Thredbo.
Photography: Dr Roger Harris, Trevor Lee (NSW Ambulance Service),
and Dr Michael King.
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Drew B Richardson and Sashi Kumar. Emergency response to the Canberra bushfires Med J Aust 2004; 181 (1): 40-42. [Crisis] <http://www.mja.com.au/public/issues/181_01_050704/ric10039_fm.html>