the record-setting flood of 2014 in kelantan: challenges...
TRANSCRIPT
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Introduction
Floodsareanannualoccurrenceof varyingseverities in Kelantan state on the east coastof Peninsular Malaysia. They also affect itsneighbouringstates,specificallyTerengganuandPahang.Previousfloods, includingthoseof1927and1967,wereconsideredsignificantinKelantan’shistory.The1967floodhadamajorimpactontheKelantan population; it has been estimated that70% of the kampungs (villages) in Kelantan, ornearlyhalfofthestate’spopulation,wereaffected(1).The2014floodwasthemostsignificantandlargestrecordedfloodinthehistoryofKelantan.Itwasconsideredtobea“tsunami-likedisaster”inwhich202,000victimsweredisplaced(2).Thisflood was called ‘Bah Kuning’ (yellow-colouredflood)becauseofitshighmudcontent(3,4).
Editorial
Chronology of the Flood
Torrential rains that began on the 17th ofDecember,2014,ledtoflashfloodingandforced3390peopleinKualaKrai,Kelantan,tofleetheirhomes(5).Later,threedaysofcontinuousheavyrain fell from the21st to the23rdofDecember,2014, inGuaMusang.Thiswasa record-settingrainfallof1295mm,equivalenttotheamountofrainusuallyseeninaspanof64days.Asaresult,thewaterlevelsofthreemajorrivers,theSungaiGalasinDabong,theSungaiLebirinTualangandthe Sungai Kelantan, rose drastically above thewaterlevelsconsidereddangerous(6). ThehighestrecordedleveloftheSungaiGalasinDabong,GuaMusangwas46.47metres(dangerlevel:38metres),thehighestrecordedleveloftheSungai Lebir in Tualang, Kuala Krai was 42.17
The Record-Setting Flood of 2014 in Kelantan: Challenges and Recommendations from an Emergency Medicine Perspective and Why the Medical Campus Stood DryKamarul Aryffin Baharuddin1, Shaik Farid aBdull WahaB1, Nik Hisamuddin nik aB rahman1, Nik Arif nik mohamad1, Tuan Hairulnizam Tuan kamauzaman1, Abu Yazid md noh1, Mohd Roslani aBdul majid2
1 Department of Emergency Medicine, School of Medical Sciences, Universiti Sains Malaysia, Health Campus, 16150 Kubang Kerian, Kelantan, Malaysia
2 School of Medical Sciences, Universiti Sains Malaysia, Health Campus, 16150 Kubang Kerian, Kelantan, Malaysia
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Abstract FloodsareconsideredanannualnaturaldisasterinKelantan.However,therecord-settingfloodof 2014was a ‘tsunami-likedisaster’.HospitalUniversiti SainsMalaysiawas theonly fullyfunctioninghospitalinthestateandhadtoreceiveandmanagecasesfromthehospitalsandclinicsthroughoutKelantan.Theexperiences,challenges,andrecommendationsresultingfromthisdisasterarehighlighted fromanemergencymedicineperspective so that futuredisasterpreparedness istrulyapreparation.ThehistoryofhowthehealthcampuswasconstructedwiththecollaborationofPerundingAlamBinaandPerkinsandWillisofChicagoiselaborated.
Keywords: floods, natural disaster, emergency medicine
Submitted:1Feb2015Accepted:3Feb2015
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metres(dangerlevel:35metres),andthehighestrecorded levelof theSungaiKelantanwas34.17metresatTanggaKrai,KualaKrai(dangerlevel:25 metres) and 22.74 metres (danger level: 16metres)attheGuillemardBridgeinTanahMerah.Thehighest levelof theSungaiGolokatRantauPanjang was 10.84 metres, which was over thedangerlevelofninemetres(7)(Figure1–7).
Emergency Medicine Experiences and Challenges
Disaster medicine (DM) is a medicalspecialty, meaning that any medical doctor canpursue it.However,emergencyphysicians (EPs)are often required to play key roles in disastermanagement (8). Themost important topics inthis specialty include disaster mitigation andpreparation,aswellasthecreationofaproperlydesigned and effective disaster response andrecovery plan. This is essential to minimising
physicalandpsychosocialcasualties. Unlike other flood disasters that hadmanycasualties (9) anddeploymentsofmedical reliefteams, ‘Bah Kuning’ in Kelantan resulted inminimalcasualties,withonly13deathsrecorded(7), and no relief teams were deployed fromHospital Universiti Sains Malaysia (HUSM).However,therewasasurgeofpatientsatHUSMduetotheclosureofanearbyhospital,HospitalRajaPerempuanZainab2 (HRPZ2). In fact, theonly available tertiary centre for all of KelantanwasHUSM(10).Therewasaninfluxofpatientswho presented to HUSM after HRPZ2 closedon the 25th of December, 2014. Those caseswere generally acute problems from underlyingchronic medical conditions such as acutecoronarysyndrome,acuteexacerbationofchronicobstructive airway disease, heart failure, sepsis,andotherdiseases.Table 1displays thenumberofcasesthatpresentedtotheEDatHUSMduringthe disaster. The average number of cases that
Figure 1: Kelantan Football stadiumwas filledwithfloodwaters.
Figure 2: Property damaged: Cars weresubmergedinthefloodwaters.
Figure 3: This aerial view shows housesand plantations submerged infloodwaters in Pengkalan Chepa,near Kota Baru, Kelantan onDecember28,2014.
Figure4:Housesandplantationssubmergedinthefloodwaters.
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presentedtotheEmergencyDepartment(ED)atHUSMwas180cases/day.Althoughthenumberwas not as high as most government hospitals,patientswhopresentedtotheEDatHUSMweremanagedeffectively.Mostoftheprocedureswereperformed by ED residents, including bedsideultrasounds, central line insertions, and chesttubeinsertions,untildiagnoseswereconfirmedorpatientswerestable.Accessblockbecameanissue
becauseallreferralcasesmustbereviewedintheED by their receiving departments and becauseitwasnotuncommonforbedstobeunavailable.Some of the patients were managed in ED formore than 24 hours. These patients had to bemonitored and reviewed regularly, particularlythoseintheredzone. Another challenge that was encounteredduringthedisasterwasashortageofstaff.Almost50% of the staff was affected by the floods,includingtheheadoftheEmergencyDepartment.Furthermore, there was no disaster declarationfrom the top-down at HUSM on day 1 of thedisaster,meaningthattheEDstaffhadtohandlethe situation themselves. With the increasingnumber of patients, this became a disaster forthem. Luckily,a group of medical students wasproactive in assisting the staff and managingthetriagecounter,clerkingpatientsinthegreenzone and controlling the crowd in the waitingarea (10). Their services during the eventwerecommendable,andmanyofthestaffsinEDweretakenabackbytheirinitiative. HUSM also received patients who weretransferredbyhelicopter.Themedicalevacuation
Figure5:Firemenrescuedfloodvictimsduringthedisaster.
Figure 6: Tsunami-like disaster damaged thecars.
Figure7:Propertydamaged:Houseonahouse.
Table 1:Number of cases based on zone presented toEmergencyRoomHospitalUniversiti SainsMalaysia
Day Date Redzone Yellowzone Greenzone Total1 25thDecember2014 21 82 149 2522 26thDecember2014 13 94 146 2533 27thDecember2014 25 105 153 2834 28thDecember2014 29 149 203 3815 29thDecember2014 19 103 123 2456 30thDecember2014 12 92 114 2187 31stDecember2014 12 71 121 204
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(medevac) involved 137 cases from districthospitalsandclinics(PejabatKesihatanDaerah)(Table2).Mostof thepatientswere critically illandrequiredventilatorsupport.FivecasesweretransferreddirecttoHospitalBesutinTerengganuforcontinuationofcriticalcarebecausethecriticalcareunitsatHUSMwerefullyoccupied.HospitalKuala Krai had the largest number of patientsbeingmedevac. VolunteersbegantoarriveinKelantanonthe28thofDecember,2014.Mostof thevolunteerswere healthcare providers fromuniversities andtheMinistryofHealth.Atotalof261volunteersregistered with the Volunteer Operations Office(Bilik Gerakan Banjir Sukarelawan HUSM) toassist with the administration of healthcareservices.However,someofthemhadtogotothedistrictarea,alongwithJabatanKesihatanNegeri(JKN) Kelantan and MERCY Malaysia. Table 3displaysthetotalnumberofvolunteersandtheiraffiliations. Coordinating the volunteerswith allofthedepartmentsinHUSMandJKNKelantanwasalsoachallengeduringthedisaster.
Recommendations
Medical management during any disastermust be coordinated by the individualsor organisations most experienced andknowledgeable in disaster management andshould not be based solely on the most seniorperson in an organisation. In our recentexperience during the worst recorded flooddisaster inour country,both theout-of-hospitaland in-hospital disaster responses had to beactivated due to the phenomenal scale of thefloodingbecauseitaffectedmorethanhalfofthecity and state area. Regardless of the nature of
the disaster, its management must involve fourphases: mitigation/prevention, preparedness,response and recovery. These phases must bewell coordinated across all relevant agencies,including those in both health and non-healthsectors, so that all of the activities taking placeare synchronised across all of the stakeholdersinvolved. Disaster preparedness is the crux of flooddisaster management. Recommendations froman emergency medicine perspective include thefollowing:
● A proper flood disaster preparednessplan and training for it are importantnot only for emergency medicineresidents but also for those workinginadministration.Administratorswhoarewellversedindisasterwillperformdisastermanagementmore efficiently.Ordersfromthetop-downwillimprovecoordination and provide moralsupportforthestaff.
● Standardoperatingprocedures(SOPs)need to be kept inwriting for variouslevelsofthedisasterresponse,i.e.,fromtheactivationof it tothepost-disasterphase.TheseSOPsmustbetestedanddrilled with all personnel involved atregular intervals.Drill outcomesmusthave measurable parameters for theinstitution’scontinueddevelopment.
● An effective communication systemis of paramount to the coordinationof rescue and relief operations.In the present flood disaster,the main network was disrupted
Table2:NumberofmedevaccasesduringthedisasterDate Hospital
KualaKrai
HospitalTanahMerah
HospitalTumpat
HospitalGua
Musang
HospitalPasirMas
PKDKualaKrai*
PKDPasirMas
PKDKotaBharu
Total
25thDec 3 0 0 0 0 0 0 0 3
26thDec 35 0 0 0 0 0 0 5 40
27thDec 15 2 11 0 8 6 2 0 44
28thDec 10 1 2 1 3 4 0 9 30
29thDec 18 0 0 0 0 1 0 0 19
30thDec 0 0 0 1 0 0 0 0 1
Total 81 3 13 2 11 11 2 14 137*includingretrievingpatientswhowerestrandedinpatients’houseinKualaKrai,SekolahMenengahKualaKraiandevacuationcentres(KemubuandManikUrai).
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Table3:VolunteersfromMOHanduniversitiescametoKelantantohelpthehealthcareservicesinHUSMandJKNKelantan
CenterOrigin No Doctor Paramedic/Radiographer
assistant/Driver
DateofArrival
DateofReturn
PlaceofDuty
PPUM/UITM 50 35 14SN/1MA 28/12/2014 2/1/15 JKN
PPUKM(1) 6 2 2SN/2MA 28/12/2014 3/1/15 MERCY/JKN
HKLFORENSIC 3 3 - 28/12/2014 2/1/15 HRPZ
IPHKL 10 5 5SN 28/12/2014 9/1/15 HUSM(5)JKN(5)
IKN 5 - 5SN 28/12/2014 10/1/15 HUSM
IPPT(1) 9 - 9SN 29/12/2014 5/1/15 HUSM
PPUKM(2) 9 5 3SN/1MA 29/12/2014 4/1/15 MERCY/JKN
PAEDTEAMKL 9 9SN 29/12/2014 12/1/15 HUSM(6)JKN(3)
IPPT(2) 3 - 3JXR 30/12/2014 5/1/15 RADIOLOGIHUSM
UTHM 7 1 3SN/3DV 30/12/2014 4/1/15 DIALISISHUSM
USMINDUK 1 - 1 30/12/2014 6/1/15 DIALISISHUSM
PPUKM 5 3 1SN/1MA 31/12/2014 7/1/15 DIALISISHUSM
TEAMKKM(1) 44 - 34SN/10JM 1/1/2015 10/1-14/1
HUSM(16)JKN(28)
IPPT 7 - 3DV/4TECH 2/1/2015 4/1/15 HUSM
TEAMKKM(2) 43 3 32SN/8JM 2/1/2015 10/1-16/1
HUSM(26)JKN(17)
TEAMKKM(3) 10 - 10SN 3/1/2015 10/1/15 USM
PPUKM(4) 3 3 - 3/1/2015 10/1/15 DIALISISHUSM
UNIMAS 11 5 6SN 3/1/2015 8/1,10/117/1
DABONG
UNIMAS 1 1 - 4/1/2015 10/1/15 JKN
UPM 2 2 - 4/1/2015 10/1/15 DIALISISHUSM
HOSPITALMUAR 2 2 - 4/1/2015 5/1/15 HUSM
IPPT 18 - 13SN/2MA3JXR
5/1/2015 12/1/15 HUSM
HSNZ 3 3 - 5/1/2015 8/1/15 DIALISISHUSM
TOTAL 261 73 188Abbreviation:PPUM=PusatPerubatanUniversitiMalaya;UITM=Universiti TeknologiMara;PPUKM=PusatPerubatanUniversitiKebangsaanMalaysia;HKL=HospitalKualaLumpur;IPHKL=InstitutPediatrikHospitalKualaLumpur;IKN=InstitutKanserNegara; IPPT= InstitutPerubatandanPergigianTermaju;UTHM=UniversitiTunHusseinOnnMalaysia;USM=UniversitiSainsMalaysia;KKM=KementerianKesihatanMalaysia;UNIMAS=UniversitiMalaysiaSarawak;UPM=UniversitiPutraMalaysia;SN=staffnurse;MA=medicalassistant;JXR=radiographerassistant;DV=driver;JM=communitynurse(jururawatmasyarakat);TECH=technician.
extensivelyinalmostallofthedistrict’shospitals.Thus,itiscrucialtoestablishan alternative communication systemto handle such emergencies efficientlyandeffectively.Thechainofcommandwithin this communication systemshouldbetestedfromtimetotime.
● Disaster management is amultidisciplinary activity involvingall departments in the hospital. All ofthe departments should be activelyinvolvedinmanagingcases.Teamworkandflexibilitybetweendepartmentsareessential.
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● IfanoverflowofpatientsoccursattheER,allof thegreenzonecases shouldbe diverted to a designated area sothat more critical cases (yellow zoneand red zone cases) can be managedwith the appropriate standardof care.Green zone cases should be relocatedtoadifferentareasothattheERisnotcrowdedbypatientsandtheirrelatives.Usingaseparatedisastertentwillhelpto control the crowdso that cases canbemanaged properly. These detachedfacilitiesarealsoimportantasisolationareas, especially when managinginfectiousdiseasecases.
● HUSM received a large number ofpatients who were transported byhelicopters over the five days of thedisaster. SOPs should be written todirecttheflowofsuchpatientsfromthehelipadtotheER.
● During any disaster, a sudden influxofbothhealthcareandnon-healthcarevolunteerworkersshouldbeexpected.Protocolsneedtobeinplacetomanageandcoordinatethesevolunteerssothatmanpowerspecialtiesarechannelledtospecificareasinthebestpossibleway.Thisisalsotrueofmanagingincomingmedicalequipmentanddrugsduringadisaster.
● Effectivehumanresourcesmanagementis essential to ensuring adequate staffcapacity and continuity of operationsduringadisaster.Hospitalstaffcontactlists should be regularly updated.Ensuring adequate staff for shiftrotations and caring for their welfareaidsinsupportingmoraleandreducingmedicalerrors.
● Flood-prone areas and supply roadsshould be mapped manually or usinggeographicalinformationsystemswithoverlying existing healthcare facilitiestoidentifyunaffectedareasandclinics/hospitals.Thisisimportantforplacingpre-planned medical equipment atstrategicsites forswiftmobilisationtofloodedareas.
Becausenoonecanguaranteethattherecord-setting flood of 2014 will not recur in 2015 orthereafter, disastermitigation andpreparednessarewithoutadoubtthebestwayforward.
How a Plan to Build a Medical Campus in Kelantan 35 years ago saved nearly 2000 patients
The initial year (1979–1980) of planningfor theUSMcampus inKubangKerianwasnotwithout problems, as approvals for the scope ofworkandtheappointmentofbuildingconsultants(involvingtwofailednegotiations)bytherelevantauthorities took time.Approval for the scope ofwork from the JPPN (National Committee forPlanning&Development)wasreceivedinAugust1980,whichincludedanallocationfora1200-bedHUSM.InSeptember1980,aspecialcommitteechaired by the Chief Secretary (KSN)made thedecisiontoinvitefivelocalarchitecturalfirmswithinternational partnerships to submit technicaland financial proposals. Then, in November1980,approvalwasreceivedfortheappointmentof Perunding Alam Bina (PAB) in collaborationwithPerkinsandWillsofChicago(thesecondtophealthcaredesignerintheUSatthattime). Withthisappointment,twoworkingsessionswere held with the consultants in December1980andJanuary1981todevelopanintegrated,functional building to reflect the academicprogramme with consideration for the site’sweather conditions. Their “fast track approach”
Figure 8: The 1927 floods were the worstrecorded in the history of WestMalaysia. (source: Muzium NegeriKelantan).
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goalforcompletionoftheentireprojectwasMay1985. As the project was about to be launched,the economic recession set in, necessitatingrescheduling and repackaging of the project’simplementation. Cost-cutting was required; thespecific changes included a reduction of the 18-footbundaroundthecampusto16feet(whichisstillabovethe leveloftherecordfloodsof1927)(Figure 8). The two floors above the OperatingTheatreComplex(designedtoaccommodatefoursurgical-based wards) were also removed fromtheproject thoughthepilingworkwasdesignedforfourfloors(11).
Correspondence
AssociateProfessorDrKamarulAryffinBaharuddinMD(USM),MMed(Emerg)(USM),OHD,AMDepartmentofEmergencyMedicineSchoolofMedicalSciencesUniversitiSainsMalaysiaHealthCampus16150KubangKerianKelantan,MalaysiaTel:+609-7673219Fax:+609-7653370Email:[email protected]
ProfessorEmeritusDato’DrMohdRoslaniAbdulMajidMBBS(Mal),DTM&H,DPath,DCPFounderDeanSchoolofMedicalSciencesUniversitiSainsMalaysiaHealthCampus16150KubangKerianKelantan,MalaysiaTel:+609-7673000Fax:+609-7653370Email:[email protected]
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