Rural GP reflects on training reality check in Christchurch earthquake
Tears rolled down a doctor's cheeks as he tried to save a young woman's life.
In a first-world country, this shouldn't be happening. But doctors tending to the wounded in Christchurch's Latimer Square were thrown into third-world like conditions when the February 22, 2011 earthquake hit, Cromwell-based Dr Pragati Gautama told a Civil Defence conference in Queenstown.
The woman was unconscious and suffering severe crush injuries to her torso. She had been pulled from the collapsed CTV building, which claimed 115 lives, and was lying in a make-shift hospital tent surrounded by a team of doctors.
"You could not have had a better resuscitation team – you had about three paediatricians, two A&E doctors, a hospital doctor a GP and number of junior doctors. There were eight doctors around her. We got a line in, fluids in then we realised she lost her heart rate, started CPR got adrenaline in. We got to about 25 minutes and every time we thought we had a great pulse it dropped and we had to continue CPR."
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With Christchurch Hospital at capacity, the doctors were told patients were being flown to Wellington, but only those who could survive a flight.
"We didn't have any form of drugs that could perhaps keep the heart going. She had to be able to have a heart rate. With a crush injury like that...It started to dawn on a few of us that she wasn't going to make it.
"People were saying, 'we have to keep going, we have to keep going'. I remember looking at a guy – he was a paediatric consultant doing the airway spills and he was literally crying."
It took another 20 minutes for the group to unanimously decide to stop.
"It was the most heart-wrenching moment to say 'enough', because growing up in a first world country you have got the resources and suddenly we realised we didn't have the resources. It was the hardest thing."
It took another 30 minutes for the woman to take her last breath.
"Although the patient was never going to make it, the patient still had a little bit of a pulse. We wouldn't have been able to get her up to Wellington. That was a very difficult moment. It took a quite a while, well for some it has taken years (to get over)."
Several hours earlier, this same group of doctors had been on the 14th floor of the Grand Chancellor building about to launch into day three of a trauma training course. Gautama was starting a session on paediatric life support when at 12.51pm it felt like a "great big giant had walked in, picked up the building and slam dunked it". The windows blew out, lights were off, dust was everywhere and everyone was on the floor.
A colleague had the foresight to open a door when the shaking started, so the group was able to get out of the room, and kick in doors where others were trapped.
"We literally assigned two or three people to each door and started kicking. There was myself, with two pieces of metal in one leg from a skiing accident, another woman who was an A&E consultant [and] was 24 weeks pregnant. Here we were two women kicking down a door."
With the stairwell gone, they escaped the shaking building through external stairs through the car park. Once on the ground, the days of training was put into practise as the doctors split into their training groups, each led by a senior doctor, and "frog-marched" down the street.
As a "traumatised" looking police officer directed the group where to go, they found themselves walking past the CTV building and ending up at Latimer Square.
"Somehow, in those first minutes, first aid kits were handed to us so some of us had gloves on. I do remember that it wasn't long after, when there was a dead body put under a tree...There was a real sense we were going to work. Effectively what we did was organise ourselves into teams where more senior doctors would help triage and more junior doctors would deal with the hands-on."
For the first couple of hours the doctors improvised with what they could.
"It was fascinating what we could do with little bits of duct tape. I was quite amazed how in lacking in pain some people were. I remember a woman trying to walk who had a fractured femur. I think because the majority were thinking, 'I am alive', 'we are not in that rubble'."
The response from colleagues was also interesting, she said.
"They really were shell shocked and I have been thinking about it ever since. Those of us who seemed to do better were the ones that already frontline doctors – A&E doctors, rural hospital doctors or rural GPs, because you encounter it all the time."
With Christchurch Hospital over-flowing with patients, the Latimer Square doctors started getting critically ill patients brought to them.
"There was a time when we were seeing quite a few people coming through in that first four hours then it went a bit calm and then they started managing to get people out of the CTV. Some of those individuals were absolutely freezing cold, drenched with water because there were monsoon buckets coming in, and they were terrified. Some were not New Zealand nationals and couldn't speak our language. They came in with various levels of crash fractures and all the rest."
Sometimes they had to go to the patients.
During the night, search and rescue approached the doctors asking them to amputate a young man's leg. The man was stuck in the CTV building and rescuers had dug a tunnel to him.
"We were all looking at each other going 'what?', 'OK'.
Despite having never done one, Gautama put her hand up first. However, a colleague - with no children - ended up crawling through the tunnel to the man equipped with a handsaw and drugs.
"I remember thinking, 'my god, I'm going to let her go', and if there is another aftershock or earthquake she is going to die...When she came back she looked quite traumatised herself. I asked her, 'how did it go?' She said, 'you know what, it's not medicine, it's just carpentry...not only did we not manage to get him completely asleep because if we had given any more he might die, but the handsaw was useless. I had to go and ask one of those guys with a drill'. That's how she did it. We just couldn't' look at each other. We did find out later the young man had been a very good football player. But he survived. He got out."
FIVE YEARS ON
Gautama has put those lessons learned during the quake to use as a rural doctor, where she often attends prime-response callouts, and is first on the scene.
"I think what was really essential for us was having that team structure. It sounds bizarre because there was actually a hierarchy and we used it. There was a real understanding of how to triage and how to delegate, so we were able to say to the doctors who were younger, you can do this, you can put splints on and some of us more senior sat back. That actually took a bit because you are so used to doing all the stuff but you were better off having that helicopter view."
Innovation, lateral thinking and communication also helped.
"Communication was really good, we did it all the time. We had been doing this in the scenario training. You had to verbalise what you were thinking. Another thing was, we could get through this because it was business. We were doctors. We could do that stuff. We had a value. We had something to do."