|Year : 2016 | Volume
| Issue : 3 | Page : 97-101
Cloud burst in Leh: Pattern of casualties; challenges faced and recommendations based on the management of such natural disaster at multi-specialty hospital
Gautam Kumar Singh1, Anuj Bhatnagar2
1 Military Hospital, Ahmedabad, Gujarat, India
2 Classified Specialist (Dermatology), Military Hospital Ahmedabad, Gujarat; Military Hospital Dehradun, Uttarakhand, India
|Date of Web Publication||26-Sep-2016|
Gautam Kumar Singh
Military Hospital, Ahmedabad – 380 003, Gujarat
Source of Support: None, Conflict of Interest: None
Background: The night of August 6, 2010, brought a rare natural phenomenon called cloud burst, which in a fraction of second devastated many parts of Leh and its surrounding areas leading to extensive loss of lives and properties. This article aims to explore the pattern of casualties and new challenges and recommendation based on the management of such rare natural disaster at multispecialty hospital. Methods and Results: A descriptive study of total 548 cloud burst-related casualties was carried out at multispecialty hospital, Leh. Totally, 297 (54.1%) casualties were attended in the first 10 h. Totally, 128 (23.3%) patients required admission. There were 339 (61.8%) male and 209 (38.1%) female patients. Maximum numbers of patients were in age group 31–40 years followed by 21–30 years. Maximum number of cases suffered from lacerated wound (n = 269, 49%) followed by polytrauma (n = 117, 21.3%), multiple abrasion (n = 75, 13.6%), fractures (n = 38, 6.9%), chest injury (n = 26, 4.7%), pregnancy with lacerated wound (n = 12, 2.1%), and least of head injury (n = 11, 2%). 180 (32.8%) patients were having associated ocular injuries. Few patients (n = 39, 7.1%) developed dermatological conditions when they were followed up in OPD. 26 people declared dead at the reception. Only three patients had fatal outcome during hospitalization phase. Conclusion: A practical, well-coordinated, and frequently practiced hospital disaster plan is very essential to reduce morbidity and mortality. Ocular injuries were associated with most of the victims due to mud infiltration into their eyes. Information about admitted patient as well as preparation of good informative data in calamities and disaster is equally important in the management of disasters.
Keywords: Casualties, cloud burst, flash flood, Ladakh, natural disaster
|How to cite this article:|
Singh GK, Bhatnagar A. Cloud burst in Leh: Pattern of casualties; challenges faced and recommendations based on the management of such natural disaster at multi-specialty hospital. Int J Health Syst Disaster Manage 2016;4:97-101
|How to cite this URL:|
Singh GK, Bhatnagar A. Cloud burst in Leh: Pattern of casualties; challenges faced and recommendations based on the management of such natural disaster at multi-specialty hospital. Int J Health Syst Disaster Manage [serial online] 2016 [cited 2021 Mar 5];4:97-101. Available from: https://www.ijhsdm.org/text.asp?2016/4/3/97/191104
| Introduction|| |
Ladakh—“Land of high mountain passes”—is situated in the northwestern part of India, on the slopes of the Great Himalayas. Leh, the capital city of Ladakh, is situated at an altitude of 3650 m (12,000 feet). Ladakh region is known for its scenic beauty, high snow-peaked mountain, glaciers, and a center for Buddhist and Tibetan culture, which attracts Indian and foreign tourists, laborers, mountaineers, and trekkers, particularly from the month of May to September. Many laborers come from the states of Chhattisgarh, Bihar, Madhya Pradesh, or other northern parts of India to work in the construction of buildings, roads, restaurants, etc., to earn money during this season. Being a high altitude area and cold dessert this region receives very sparse rainfall. The houses are made of mud and sun-dried bricks which do not afford protection against heavy rainfall.
The night of August 6, 2010, brought a rare natural phenomenon called cloud burst, which in a fraction of second devastated many parts of Leh, and its surrounding areas leading to severe loss of lives and properties. This devastating nightmare brought often forgotten and neglected Leh, to the limelight of electronic and print media. This cloudburst left behind more than 180 dead, many still missing, severe, life-threatening injuries to local Ladakhi, tourists, laborers, and serving soldiers.
This article aims to explore the pattern of casualties and new challenges and recommendation based on the management of the rare natural disaster called cloud burst.
| Methods|| |
This was a descriptive study where all cloud burst-related casualties, who reported to the multispecialty hospital since August 6, 2010, was carried out. Data were entered in Excel sheet. Analysis of data was done in tabular fashion to know the types of casualties and their distribution as per age, gender, and residence. It was done in computer with software of Microsoft Windows 2007 (Hewlett-Packard, New Delhi, India).
| Results|| |
Totally, 548 patients were brought to hospital following the cloudburst. Most of the patients (n = 248, 45.25%) reported within 10 h of the cloud burst and rest over another 2 days. The last cloud burst patient reported on 4 September who was a case of deep plantar ulcer with toxic epidermal necrolysis (TEN) following Cap Augmentine ® (amoxicillin and clavulanic acid) ingestion. This individual was on long leave in a remote, inaccessible place called Zanskar. There were total 339 male (61.8%) and 209 (38.1%) female patients which are depicted as pie diagram in [Figure 1]. The maximum number of people were in age group 31–40 years (n = 176, 32.1%) followed by 21–30 years (n = 167, 30.4%) and least number was in age group > 60 years (n = 23, 4.1%). Bar diagram in [Figure 2] depicts age-wise distribution of casualties. There were total 315 (57.4%) Non-Ladakhi, 204 (37.2%) local Ladakhi, and 29 (5.2%) were serving soldiers. Totally, 11 (2%) foreign nationals were included in non-Ladakhi group. The non-Ladakhi people were mostly laborers from Chhattisgarh and Jharkhand state. All foreigners had only minor abrasions and minor laceration, which were managed at resuscitation site. Maximum people sustained lacerated wounds (n = 269, 49%), followed by polytrauma (n = 117, 21.3%). The distribution of patients as per their diagnosis, number, and inhabitants are mentioned in [Table 1]. Totally, 12 pregnant women also sustained injuries. Out of 12 pregnant ladies, 5 were full term who required conduction of delivery at this hospital. Totally, 3 babies were delivered by cesarean section and 2 by normal delivery by the help of local gynecologist. There was one stillbirth. Maximum number of fractures involved the clavicle (n = 7) followed by tibia (n = 6). Many other types of fracture cases were managed at this hospital, the distribution of case is given in [Table 2].
Totally, 180 (32.8%) patients had associated ocular injuries; the distribution of it is given in [Table 3]. Almost every patient of ocular injury had associated conjunctival hemorrhage. Apart from conjunctival hemorrhage, totally, 128 (23.3%) patients had foreign bodies in fornices. Totally, 3 patients developed infectious keratitis during follow-up, which were successfully managed. Three children required general anesthesia to remove the foreign bodies from fornices. Rest other required minor operative procedures.
During follow-up of the injured patient for dressing as well who reported late, totally, 39 (7.1%) dermatological conditions were diagnosed and managed. The distribution of dermatological conditions is illustrated in [Table 4]. All three cases of irritant contact dermatitis were admitted patients, who developed this due to betadine (povidone iodine) lotion application on thighs and lower limb region for dressing purpose. One Ladakhi serving soldier who was on long leave at remote place developed TEN due to cap augmentin (amoxicillin and clavulanic acid) ingestion. He was being managed by local doctor for a deep ulcer on posterior aspect of the right foot which he sustained during the flash flood. He was successfully managed conservatively without any oral steroid.
|Table 4: Types of dermatological diseases in follow-up of the disaster cases and their distribution|
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Totally, 26 people were declared “found dead” at the reception which included 3 <2-year-old girl babies, 3 serving soldiers, 5 Ladakhi males, 9 nonLadahki males, and 6 females laborers. Dead bodies were handed over to civil authorities after initial documentation. Totally, 128 (23.3%) patients were managed as admitted patients out of whom only three died in the hospital. One was 78-year-old man died of myocardial infarction who had sustained minor lacerated injury. Other case was 19-year-old girl, who died of sepsis with multiorgan failure following multiple bone fractures. Third was unclaimed body that died of the severe head injury. His DNA sample had been sent for analysis.
| Discussion|| |
Cloudbursts have no strict meteorological definition. The term usually signifies a sudden, heavy fall of rain over a small area in a short period. Cloudburst represents cumulonimbus convection in conditions of marked moist thermodynamic instability and deep, rapid dynamic lifting by steep orography. The phenomenon occurs due to sudden upward drift of moisture-laden clouds as a tall vertical column termed “Cumulonimbus clouds.” The ascending moisture-laden clouds become heavier and at certain point, they produce violent rainstorm within a short interval. The orographic lifting of moist, unstable air releases convective available potential energy necessary for a cloudburst. Similar views are echoed by various researchers. The topographical conditions such as steep hills favor the formation of these clouds. This leads to flash floods, landslides, house collapse, dislocation of traffic, and human casualties on large scale.
In one of the India's worst cloudbursts on July 26, 2005, Mumbai was completely paralyzed. Approximately, 950 mm of rainfall was recorded in India's financial capital over a span of 8–10 h.
There is no satisfactory technique for anticipating the occurrence of cloud bursts because of their small scale. A very fine network of radars is required to be able to detect the likelihood of a cloud burst, and this would be prohibitively expensive. Only the areas likely to receive heavy rainfall can be identified on a short range scale. Much of the damage can be avoided by way of identifying the areas and the meteorological situations that favor the occurrence of cloud bursts., Heavy rainfall is common elsewhere in the Himalayas, but not in Ladakh. The region lies in the rain shadow of the high mountains, making it a cold, high-altitude desert. According to the Indian Meteorological Department, Ladakh receives an average of about 15 mm of rain during August. However, between 1.30 and 2 am on August 6, 2010, a cloudburst hit Leh. It led to flash floods and mudslides, washing away houses that were not built to withstand such rainfall. More than 180 people have died, and hundreds more are still missing. There is only one civil hospital present at Leh, that is, SNM hospital which provides medical care to civilian and tourists, this also became victim of flash flood leading to an outpouring of all casualties in the multispecialty military hospital.
Like any other natural disaster, it has happened at a time when everybody was asleep. Maximum number of casualties was attended in first 10 h. The pattern of casualties was not much different from other natural disaster. However, there were few peculiarities of this disaster which are as follows.
- Occurrence in midnight when everybody is asleep
- Road was blocked with soil and stones, so casualty sites were unapproachable
- Most of the people were in unrecognizable state due to heavy cover of mud on the body [Figure 3]
- Extent of injuries was not appreciable due to thick layer of mud on the body
- Ocular injuries were associated with most of victims due to mud infiltration into their eyes [Figure 4]
- Radiography of body parts, for example, limbs, head; to assess for fractures was difficult due to thick mud. There was also inherent danger of damage to extensive X-ray machine and computed tomography scan due to the presence of mud everywhere
- Cold water of rain as well of river, endangered people to go into hypothermia
- Patients were in state of shock as everything even their kith and keens lost and misplaced in front of their own eyes.
Most of the patients had some form of ocular injuries because of the mud infiltration into their eyes. Timely dislodging of foreign bodies, frequent management of ocular injuries prevented any body to lose eye sight. Few patients suffer from dermatological conditions which are unusual in disaster. One had life-threatening TEN following augmentin ingestion which was successfully managed in dermatology ward.
Approach to management was totally based on the National disaster management policy, which is regularly practiced by all the multispecialty hospitals. A dedicated team of doctors was present at designated place, namely, reception and resuscitation, acute surgical ward, acute medical ward, crisis expansion ward, operation theater (OT), and radiology department along with their supporting staffs. Dedicated staffs were handling casualties from reception area to resuscitation area then taking them to different place as per advice of doctors. Everybody who had open wounds was given preloaded injection tetanus toxoid (TT), injection diclofenac sodium 50 mg, and injection cefotaxime 1 g. One nursing assistant was dedicated to fill the syringes for above purpose. A dedicated team of ambulance assistants was placed for receiving casualties to resuscitation area then transferring patients from resuscitation area to radiology department or acute wards or OT. The “Crisis Hall” was activated within half an hour to cater for extra casualties having capacity of 45 beds. Patients requiring urgent imaging study were sent to radiology department where on the spot decision was made of their further disposal. Those patients requiring urgent surgical intervention were sent to OT after consultation with surgeon. Those patients not requiring immediate surgery were placed into acute surgical ward and subsequently when the ward was filled, admitted to crisis expansion ward. All previously admitted patients in surgical ward not requiring acute care were transferred to chronic wards such as skin and chronic medical ward to cater for disaster casualties. Patients who had known medical condition was placed in acute medical ward. Local gynecologist was called on to conduct delivery. Three cesarean section operations were conducted successfully in this hospital which otherwise does not have gynecological facility. All endeavors were made to keep reception, resuscitation area, information desk, corridor which guide to different wards free from crowd. After declaring dead, the dead bodies were kept separately at a designated place under the supervision of senior, junior commission officer. Unclaimed and unrecognized bodies were handed over to civil authorities after keeping their DNA sample for the future reference. All vehicles, suspicious persons were enquired at the main entrance to avoid any untoward incident. Close watch over visitors was also done. Resuscitation, reception area, and ICU were under cover of close circuit camera.
While managing these casualties, this hospital adopted new methods which can be used in the future in the management of any such natural disaster. The recommendations are as follows.
- Preloading of injection TT, injection diclofenac sodium, and injection cefotaxime and giving them as stat dose to a patient who has got open wound at resuscitation site
- Delaying of suturing of contaminated wounds unless there is active bleeding which is life-threatening
- Establishment of minor OT in each ward having facility of dressing material, intravenous (IV) fluids, and IV antibiotic
- Ocular injuries to be given similar priority as any case of fracture
- To save the time and damage to the equipment, a large number of patients can be X-rayed on the stretcher itself
- Stocking of the antibiotic which are going to be used in casualty such as injection cefotaxime
- At the end of the day, data making in the informative format so that it can be dissipated to the higher authorities in administration
- Powerpoint presentation of the photographs with name of admitted patient can be flashed at information desk along with the list of patients which are being managed in the hospital
- Warm water supply to be provided in plenty for bathing and cleansing purpose. All patients requiring OT procedures were washed and cleansed with warm water outside OT so that sterile environment of OT is not compromised
- Large number of patients required cutting and shaving of hair from the scalp for OT procedures. Hairdresser or hired barber can be employed to expedite the procedure
- Breakfast which can be made in plenty and quickly like salted pudi and tea should be made available as soon patients are stabilized
- Regular follow-up of the injured victim should be advised to manage the wound infection or any new development of contagious disease which might arise in the camp like situation. In this context, large number of flash flood victim was treated on time for dermatological conditions.s
| Conclusion|| |
Cloud burst is very uncommon natural disaster if it happens to a place where infrastructure and geography are not adapted leads to extensive damage to human lives and properties. A practical, well-coordinated, and frequently practiced hospital disaster plan is very essential to reduce morbidity and mortality. The extent of injuries on body as well as in the eyes can be missed if person is covered with mud. Information about admitted patient as well as preparation of good informative data in calamities and disaster is equally important in the management of disasters. Follow-up of the injured patients is equally important to prevent wound infection or any impending epidemic contagious infection which might add to the agony of the natural disaster. Innovative steps taken during managing this disaster would certainly help in handling any such future disaster with greater ease.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4]