(Brussels, December 6, 2006) For any Disaster Relief Task Force, the call to work abroad — or indeed in some cases from home — naturally presents an opportunity but also brings with it a harsh and stark reality, and uncertain and often dangerous implications.
ISN's response to Pakistan's worst-ever was to immediately call in its Renal Disaster Task Force, under the leadership of Raymond Vanholder. In collaboration with colleagues from Medecins sans Frontières, ISN scouts remained on the ground in Islamabad from the very outset until intervention was finally completed on October 31, 2005.
Throughout the entire period ISN volunteers regularly reported back to Headquarters on the scale of this catastrophe and predicted the likely knock-on effect on the demand for dialysis and number of crush syndrome casualties on a daily basis.
Below is a diary account of key developments and actions reported by the ISN team that acted on the Asia Quake.
October 10, 2005
*Teams from Médecins sans Frontières (MSF) were already working in the affected area when the earthquake struck and are rushing to offer aid in the most damaged of zones.
*A new team from Médecins sans Frontières (MSF) with one ISN nephrologist/intensivist (E.Hoste, Gent, Belgium) and one dialysis nurse (S. Claus, Gent, Belgium) arrived today in Islamabad Airport at 5.30 am local time. The team carried kayexalate and dialysis catheters with it.
*Local doctors have referred to preliminary estimations of at least 100 crush cases in Islamabad, spread over 4 hospitals. Hospitals in the Kashmere area with dialysis facilities have probably been destroyed. There are few care units and of little use in acute renal failure.
*S. Nayyer Mahmud volunteered to liaise with us on the local situation and coordinate activities.
*The need for dialysis machines, nurses, technicians and doctors is likely to be high on the agenda. We wait for further news from our scouts before activating groups who are already on emergency stand-by.
*Drs. Najafi and Broum and (Iran), Jha (India) and Sever (Turkey) expressed their wish to help. It may well be necessary to evacuate victims from Pakistan to provide care in foreign countries.
October 12, 2005
*Our scouting team (E. Hoste, S. Claus) together with the scouts from Médecins sans Frontières reached Islamabad early yesterday morning, visited the local hospitals, took part in a coordinating meeting organized by WHO with the other rescue teams, and have visited the dialysis unit in Abottabad to make improvements. They have now returned to Islamabad.
*Following many telephone conversations with several Pakistani doctors at present not many crush patients have been reported, and only very few ARF. The number of dialyzed ARF patients in Islamabad can be estimated at some 10-15 maximum with 3 in Abottabad. There are some 3 times more ARF patients without dialysis needs. Fluid administration is being carried out effectively. The low number of ARF can to a large extent be attributed to the huge logistical difficulties concerning extrication, evacuation and transport.
*Evacuation aid has increased over the last 24 hrs, which may affect the number of incoming patients over the next few days.
*At present there is no immediate need to call in extra personnel from abroad; there may be a need for extra dialysis machines. We contacted industry about this matter and they will contact the respective doctors.
*A. Ravi's team has set up a mobile dialysis unit in Abbottabad with 6 dialysis beds and 4 ventilators. They placed another 2 bed units in Mensara in the damaged area and are searching for other potential locations. All is currently under control.
*For the time being, it seems that no further teams will have to be sent. We will keep the scouts in place for longer to assess whether the number of incoming ARF victims is likely to increase.
October 14, 2005
*Initial reports showed a small number of Acute Renal Failure (ARF) cases — certainly due to difficulties in extrication and transportation. At first glance it appeared that everything was under control, but, as of yesterday it became increasingly apparent that the infrastructure in Islamabad PIMS (Pakistan Institute of Medical Science) hospital required optimization, since it has become a major reference center for the heavily wounded. At the same time, the influx of ARF patients is escalating. Many of the dialysis machines in place at the intensive care unit have already broken down.
*Responding to these alarm bells, ISN appeals to industry for back up support and cargo with dialyzers and peritoneal dialysis fluid is ready to leave from Germany, tomorrow or the day after. Further talks with industry are underway.
*Currently the number of ARF patients needing dialysis is estimated at 15, but this number is on the constant increase. There are probably still ARF patients in non-nephrology units.
*Cargo from MSF Belgium will leave with one reverse osmosis machine, 4 dialysis machines, tubings and blood lines. The incoming team will also bring dialyzers and blood lines with them in their hand luggage.
October 15, 2005
*The ISN team composed of 1 doctor (D. Erbilgin, Arles, France), 3 Belgian nurses (K. Roels, Gent; R. Vandam, Antwerp; H.Leers, Gent), 2 French nurses (A. Schott, Arles, D. Borniche, Rouen) and one technician (P. Stockman, Kortrijk, Belgium) leave for action, estimated to arrive in Islamabad tomorrow morning.
The group will concentrate on trying to identify new ARF cases outside the nephrology department of our reference hospital in Islamabad (PIMS), outside PIMS and outside Islamabad and D. Erbilgin traveled to Rawalpindi to assume this role.
*D. Erbilgin will also give an educational course surrounding ARF and the Task Force for the local doctors in Islamabad.
*P. Stockman (our technician) and S. Claus (the scout-nurse who arrived with the first team) are working hard to repair the damaged dialysis machine park at the PIMS intensive care.
*The cargo with 4 dialysis machines and an RO system made at disposition by the Task Force, has arrived in Islamabad, and the material will become available around 9.00 pm local time tonight.
*An Iranian team under the leadership of M. Mazdeh is active in the border between Kasmir and Iran. The Pakistani team under A. Rizvi is active in Abbottabad, on the boarder of the damaged area, 2 hrs driving up North of Islamabad. They are endeavoring to set up put up mobile dialysis posts in the damaged area, e.g. in Menshara.
October 16, 2005
*The second team that left yesterday arrived in Islamabad early this morning.
October 17, 2005
*E. Hoste (our scout intensivist) returned safely to Belgium yesterday.
*S. Claus will return tomorrow, to be back in Belgium Wednesday morning 19/10.
*The number of dialyzed ARF cases is rising progressively and we are aware of at least 30 cases in the Abbottabad - Islamabad area.
*A. Rizvi's Team continues to treat patients at 3 locations with Abbottabad as the Headquarters. It has been suggested to move these patients to Islamabad for safety reasons (risk of aftershocks).
Conveys on the road to the disaster area
October 19, 2005
*S. Claus, the nurse scout who participated in the first wave of aid, has left Pakistan and now returned safely to Belgium.
*The current team, composed of 1 nephrologist, 5 nurses and 1 technician, continues working at the PIMS hospital in Islamabad.
*The number of dialyzed ARF patients in the area surrounding Islamabad currently stands at 43. The number in Islamabad is considered stable. The conditions have been optimized, e.g. several of the previously collapsed machines in the machine park have now been repaired.
*After extensive consultation with our MSF colleagues and with the team in Islamabad, we are considering extending aid by sending a third team, with more emphasis on the medical aspects with scouting and retrieval of yet unknown ARF cases in and around Islamabad. A team comprising 3 nephrologists, 3 nephrology nurses and 1 technician is envisaged. The nurses and 1 nephrologist would in principle care of the clinical aspects in PIMS. The other nephrologists would concentrate on aspects outside PIMS scouting around the hardest hit areas, including Mozzaraffabed, Bagh and Menshera. Since the local situation is changing continuously, however, we are reporting this information with a certain sense of hesitancy since there is still some chance that an extra new team may not be necessary.
October 21, 2005
*P. Stockman, our technician, who was so instrumental in repairing the broken down dialysis machines in Islamabad when we arrived, returns home to his wife who will be having a baby within the next few days.
*D. Erbilgin, the nephrologist who currently coordinates our team will return home after the weekend, with some overlap with the new incoming team.
*A maximum of 60 dialyzed ARF patients have been located in and around the Islamabad/Abbottabad area. Around 40 are still currently on dialysis. There are at least as many non-dialyzed patients.
*The new team will be coordinated by our Turkish colleague, M. Sever who also served as the local coordinator for the ISN/Renal Disaster Relief Task Force (RDRTF) during the Marmara earthquake in Turkey in 1999. M. Sever leaves Istanbul tonight, at 11:05pm to reach Islamabad tomorrow at 5:30pm.
*The team is further composed of a second Turkish Nephrologist (M. Koc) alongside a Belgian Nephrologist (A. Van Der Tol), 3 renal nurses (A. Scheir - Belgium, E. Ünal - Turkey, H. Dunlop - N. Ireland) and 1 technician (G. Leroux - France).
*As well as continuing with current in-hospital activities at PIMS hospital in Islamabad, the team will also concentrate on detecting ARF outside both the hospital and the Islamabad area. They will also be instructing on educational aspects regarding ARF aimed at non-nephrologist doctors.
*The new team will be traveling with extra artificial kidney and blood lines in their hand luggage.
The ER in PIMS hospital (Islamabad) early days and already a mass influx.
ISN Relief Task Force volunteer, EricA.J.Hoste on the scene inserting a dialysis catheter in a patient with ARF in PIMS Hospital, Islamabad.
October 24, 2005
*D. Erbilgin, our previous coordinator, left Pakistan Saturday morning and was replaced by Mehmet Sever from Istanbul, Turkey.
*The rest of the previous nursing team remains active in Islamabad, joined by a new team which arrived safely on Sunday morning.
*The number of ARF patients has stabilized. There are some 20-30 ARF patients still on dialysis in the Islamabad area. The patients treated by our team in PIMS hospital remain to a large extent on dialysis. Obviously we have dealt with the most severe cases. Many of them remain anuric suffering from serious infection.
*Our team has been helped a lot by the local team of S. Khan in treating patients, in screening other hospitals and in compiling statistical evaluation of the day to day changes.
*M.Sever circulated a questionnaire, similar to the one used for the Marmara earthquake, to distribute among doctors in Pakistan, and to allow an epidemiologic evaluation of the situation.
*Most of the technical problems have now been solved by our technicians and we have received help from dialysis companies (essentially Gambro and Fresenius Medical Care).
*We are still considering sending another team. Three potential candidate nurses have been contacted and are on standby.
October 26, 2005
*Following consultation and discussion with MSF Belgium, and the local MSF-team in Islamabad, it was decided not to send an additional team to Islamabad. Reasons behind this decision were the improving condition of patients, the difficulty of setting time schedules of the different teams to fit with one another, and the problem of finding a coordinating nephrologist with enough disaster relief experience.
*The first initial team members have now all withdrawn from Pakistan.
*All members of the second team are still in place, and will leave - one by one - from next Friday onwards. The two renal nurses are scheduled to leave on November 1.
*M.Sever, the current team coordinator, will leave tomorrow. His duties will be assumed by T. Imam, a doctor who resides in the US of Pakistani origin, who is scheduled to stay on the ground until November 3.
*M.Sever is collecting more precise statistical information about epidemiology, based on a questionnaire which he developed for the Marmara earthquake in 1999.
*The following has been delivered: kayexalate, dialysis catheters, spare parts for broken down machines, blood lines, dialysis machines and dialyzers. The following professionals contributed: nurses, technicians, and doctors of French, British, Turkish, and Belgian nationalities. Our teams will have been in Pakistan for a total of 22 days.
*A more detailed and final communication will be provided after finalization of the ISN's Renal Disaster Task Force's mission (scheduled for around November 3).
October 27, 2005
*A. Hussain is appointed as the new contact person at the local level once the ISN team withdraws.
*A. Scheir reports back that patients are improving day by day — several of which no longer need dialysis.
October 29, 2005
*S. Khan reported on latest statistics: 62 dialyzed ARF (+15 listed by A. Naqvi), 11 died, 82 non-dialyzed ARF.
*Sudden influx of patients at PIMS hospital coming from other hospitals. Initial estimation given the extra renal failure patients that a further nursing team will be required.
*Only two of the new patients required dialysis. Unfortunately one chronic dialysis patient who had not been treated from the outset because of a destroyed dialysis unit in Muzaffarabad, died soon after his admission.
*It was decided that no new team was needed for the time being. 3 patients still remain on dialysis.
*M. Sever sent approximation on final statistics: 50 hemodialyzed ARF and 82 non-dialyzed crush.
October 30, 2005
*Educational difficulties reported by A. Scheir in convincing Pakistani nurses to learn new techniques and work with new machines.
*Dialyzed patients: 3.
October 31, 2005
*The final two ISN Renal Disaster Task Force volunteers return home. ISN's intervention and aid on the ground completed. Time to return home.
*Final statistics: As a reflection of the outstanding work of all ISN volunteers and collaborators, out of a total of 118 victims with ARF, 100 survived having been treated by dialysis. Medication, treatment, and other support was given to a further 80 crush victims for whom dialysis was not necessary.
Member Discount on Crush Syndrome Book
In the days following another horrific earthquake, which occurred in Marmara, Turkey in 1999, the Turkish Society of Nephrology, in collaboration with ISN's Renal Disaster Relief Task Force, prepared special questionnaires to obtain patient data and follow-up information to analyze the extent of the nephrological problems. A recent book, entitled The Crush Syndrome (and Lessons Learned from the Marmara Earthquake), is based on the 639 cases documented, constituting an unprecedented collection of first-hand experience on crush syndrome-related ARF following earthquakes. In addition to the data and analysis gained from the Marmara earthquake, each chapter also summarizes classical information on crush syndrome.
ISN Members benefit from a special discount of 20% off the cover price.
Members pay £ 48.50 / US$ 62.00 instead of £ 60.50 / US$ 77.25. Remember to mention ISN membership in the 'Comment' field when ordering online to receive the special discount.
More information and online ordering.
The Crush Syndrome (and Lessons Learned)
