ghaisal train accident 2002

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(COL.) PRABHAKAR, YOGESH : GHAISAL TRAIN ACCIDENT 409 Indian J. Anaesth. 2002; 46 (5) : 409-413

GHAISAL TRAIN ACCIDENT

Col T. Prabhakar, VSM1 Col Yogesh Sharma, VSM2

SUMMARY

With the ever-increasing mechanization, vehicular accidents are steadily increasing in magnitude and frequency. Large sections of

the population use some form of mass transportation like trains, buses and airplanes etc. Any accident involving these means of mass

transportation could have disastrous consequences. In this presentation we would like to share our experience at 158 Base Hospital regarding the management of victims of a train accident resulting from a head on collision between two fast moving passenger trains.

The sudden deluge of 149 casualties including 46 dead although stretched our medical resources but helped us in fine-tuning our

disaster management plans. Some unusual and interesting patterns of injury were encountered.

Keywords : Disaster management, Railway accident.

Introduction

Trauma, called the neglected child of modernsociety is the principal cause of death and disability in the

first three decades of life.1 Although authentic data

regarding mortality and morbidity following trauma is

hard to get, trauma accounted for over 43 lakh victims

which included 7 lakh dead in India in 1994.2

The economic loss to the nation is staggering in

the form of loss of millions of work hours added to the

cost of treatment. Improvements in prehospital trauma

care, establishment of regional trauma care centers, use

of safety devices like seat belts, improved automobile

design and imposition of speed limits have reduced death/

disability rates but a lot still requires to be done. 158Base Hospital was exposed to an influx of mass casualties

resulting from one such unfortunate train accident. An

effort has been made to outline the profile of injuries and

to share our experience in their management.

Materials and methods

In the early hours of 02 August 1999 the Delhi

bound Avadh Assam Mail collided head-on into the Gauhati

bound Brahmaputra Mail at GHAISAL (Fig 1,2,3). It

was one of the worst train accidents in the country, which

left more than 800 people injured and 256 dead. 103 of

the injured and 46 dead were received at 158 Base Hospitalon 02 and 03 August 99 within a period of about 36

hours. Although a few hours prior information about the

arrival of mass casualties was received the sudden influx

of such a large number of casualties pushed the entire

hospital services to perform beyond themselves in order

to manage this disaster.

1. MD., Senior Advisor(Anaesthesiology), 158 Base, Hospital; C/O 99 APO

2. MS (Gen Surg), MS (Ortho),Classified Specialist (Surgery & Ortho),Command Hospital; Chandigarh

Figure : 1

Figure : 2

Figure : 3


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INDIAN JOURNAL OF ANAESTHESIA, OCTOBER 2002410

All the patients had been given first aid at the siteof accident by the meager local medical resources. Inaddition one surgical team of 158 Base Hospital went to

the accident site to organize the evacuation of casualties. All the cases were received at a special reception center for first aid and documentation. Each case was seen on arrivalby a surgeon and allotted priority in the usual manner i.e., P-1 cases requiring immediate resuscitation and urgentsurgery (these included open intraarticular fractures) P-2cases requiring possible resuscitation and early surgeryincluding dislocations and open fractures. P-3 for all other cases. In addition special priorities were allotted for spinaland eye injuries. Resuscitation was carried out along witha quick primary survey and continued in the operationtheatre/acute wards as indicated. All cases with openwounds were given tetanus prophylaxis and antibiotics.

Subsequently the injuries were regionalized. Lifeand limb saving surgeries were carried out as per priorityalready allotted. Later the complete nature of injurieswere determined and secondary procedures carried out.Injuries requiring treatment at specialized centers wereidentified and evacuated to appropriate centers.

Some of the patients arrived in a shocked statebecause of multiple injuries, airway obstruction, massivebleeding or other trauma requiring urgent resuscitationand early surgery. Patients were provided uninterruptedintensive therapy in severe trauma cases followingoperations that have suffered critical hypotension or

hypoxia preoperatively or intraoperatively. There wereno delayed operations or premature interferences.Diagnosis and treatment were occurring simultaneously.

Anaesthesia was administered and maintaineddespite poor patient status and staffing, sometimes withoutthe benefit of supportive laboratory and previous medicaldata. There were high incidence of critical events likeoften lengthy operating procedures, multiple, serial or simultaneous diagnostic or therapeutic procedures. Four patients required ventilatory support and one of themrequired ventilation for ten days. All the patients weresuccessfully weaned off the ventilator.

Results A total of 149 cases were received in a period of about 36 hours, these included 46 dead. Out of the injuredthere were 99 males (96.1%) and 04 females (03.89%). Of the 103 injured, 72 cases (70%) were Army personnel, 09(08.7%) were from Assam Rifles, 06(05.8%) each from Air force and CRPF. There were 07 civilians and threecases from other paramilitary forces. All the injured weretraveling in the leading compartments of the two trains. After triage the distribution of cases were as per Table-1. A total of 17 units of blood transfusion were given. Nosingle case required more than 04 units of blood transfusion.

Regional distribution of cases is given in Table-2.

Table 1 : (Triage)

PRIORITY No of CASES PERCENTAGE

Priority-1Polytruma

Thoracic injuries 12 11.66%

Open intra-articular fracture

Priority-2

Acute dislocations

Open fractures 31 30.01%

Others

Priority-3 55 53.59%

Special priority

Cervical spinal injury 05 04.95%

Dorsolumbar injury

Table 2 : Regional distribution of injuries

S. No REGION No of Cases

1. Multiple superficial injuries 68

2. Lower limb injuries 33

3. Upper limb injuries 17

4. Thoracic injuries 14

5. Dislocations 09

6. Head, neck & spine injuries 08

7. Polytrauma 05

8. Major lacerations 04

A total of 149 active procedures were carried out

during the course of management of the accident victims.The various interventions are listed in Table-3 (Surgicalprocedures/interventions). There were 40 major injuriesto the lower limbs in 33 cases. These included 32 fractures,07 dislocations and one case of anterior compartmentsyndrome in the leg. Description of the lower limb injurieshas been given in Table-4 (lower limb injuries). Details

of upper limb injuries are given in Table-5.

Table 3 : Surgical interventions

S No. SURGICAL INTERVENTION No

1. POP application 43

2. Suturing of lacerations 38

3. Closed reductions 20

4. Wound debridements 17

5. ORIF (Open reduction internal fixation) 15

6. Skeletal tractions 10

7. External fixators 08

8. Exploratory laparotomies 03

9. Amputations 02

10. Ventilatory support 04

11. Tracheostomy 01


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INDIAN JOURNAL OF ANAESTHESIA, OCTOBER 2002412

the time required for medical treatment at the scene is

equivalent to 20% of the total scene time, thus

representing only a fraction of the total pre hospital

time. Correlating the total pre hospital time or scenetime to outcome therefore appears absurd. The treatment

principle of aggressive shock in poly trauma needs critical

reevaluation on the basis of results obtained by recent

preclinical studies in patients with penetratrating torso

injuries. Small volume resuscitation could not be

demonstrated to improve outcome in polytrauma patients,

although a slight improvement with brain injury may be

assumed. Endotracheal intubation and early artificial

ventilation are proven therapeutic principles in

polytraumatised patients.7

Ghaisal is a small village and evacuation of

casualties to Siliguri required lot of transport and thedistance is 90 kilometers. In Army we use the McPherson’s

formula to deal with such problems.

(a) To find out the time required : T=1/M x W x t/N

(b) To find out the amount of transport required to

evacuate in a given time :

M = 1/T x W x t/N

Where M = Units of transport required or

available

T = Time allowed

W = Number of sick and wounded

t = Time taken by transport for one

journey and return

N = Number of patients each unit of

transport carries.

By knowing the variables, you can calculate the

number of ambulances required for transportation of

the casualties. In the usual method of allotment of

priorities (triage) threat to life has been the only basis of

allotment of priority; the morbidity potential has not

been given due weightage. Standard acceptable figures

of P-1,P-2,P-3 accounted for 10%, 20% and 70%cases respectively. In our series there were 11% cases of

P-1, 30% P-2 and 59% P-3 cases. The difference is due

to the fact that we have included open intra articular

fractures in P-1 cases and open fractures and dislocations

in P-2 cases. This has been done due to the fact that

any delay in treatment of open fractures, dislocations

and open intra-articular fractures can result in

considerable morbidity. Comparison of regional

distribution of injuries in various disasters3 is brought

out in Table-6. The difference between our series and

other series can be explained by the vastly different

mechanism of injury in war wounds which are caused by

blasts and projectiles and those caused by sudden

deceleration as seen in the Ghaisal train accident.

Table 6 : Comparison of regional distribution of injuries (3)

INJURY KOREAN INDO-PAK 158 BH

WAR (%) CONFLICT (%) EXPERIENCE (%)

Head injury 15 01 07.7

Thoracic injury 19 12 13.6

Abdominal injury 11 13 2.9

Upper limb injury 25 22 16.5

Lower limb injury 27 69 32

Anaesthesia for trauma patients is challenging. Theproblems were high workload, physical, high psychological

and emotional stress. The moment-by-moment care by

titrating, so crucial for patients with life threatening injuries

is difficult and it should be done with utmost care and

devotion, unmindful of personal comfort.

Missed injuriesMass casualties present with confusing and

continuously changing situations. Various reasons such as

haemodynamic instability, polytrauma, altered sensorium

and low index of suspicion can contribute to missed

injuries. Table-7 provides considerable figures for

missed injuries in various studies. Wide variation in theincidence of missed injuries is perhaps due to the absence

of clear-cut guidelines regarding what constitutes a missed

injury.

Table 7 : Comparative figures of missed injuries

STUDY TYPE No of CASES MISSED

of TRAUMA INJURIES

Albrektesen SB Blunt 218 75(34%)

Thompson JL (1989) (5)

Chan RNW, Ainscow D Blunt 327 39(12%)

(1980) (4)

Enderrson BL, Stevens SL Blunt 399 36(11%)

De Boo JM (1990) (6)

158 BH Experience Blunt 103 06(5.08%)

Unusual patterns of injuries observed

• The high number of casualties received in a short

period of 36 hours

• Extrication problems were acute being a railway

accident and was responsible for some of the unusual

pattern of injuries.


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(COL.) PRABHAKAR, YOGESH : GHAISAL TRAIN ACCIDENT 413

• The high incidence of grade 3 open tibial fractures

and the use of external fixators

• The unusually high number of dislocations of hip

• The three cases of closed crush injuries of upper

limbs (All had complete motor loss in upper limbs

without sensory impairment and their subsequent

spontaneous recovery)

• The two cases of ARDS

• Burns and penetrating injuries were conspicuous by

their absence

References

1. James R. Macho, MD, Frank R. Lewis, Jr., MD, & William

C. Krupski, MD, Management of the injured patient, In:

Lawrence W Way, Editor, Current surgical diagnosis and

treatment, 10th ed. Appleton and Lange, USA, 1994;213-225.

2. Indrayan A, Epidemiology of Trauma deaths in India in

Principles and practice of trauma care (Ed) Kocher SK, Jaypee

Brothers Medical Publishers (P) Ltd, New Delhi, 1998; 1-12.

3. VK Sinha, Management of ballistic injuries in : Principlesand practice of trauma care (Ed) Kocher SK, Jaypee Brothers

Medical Publishers (P) Ltd, New Delhi, 1998; 32-47.

4. Chan RNW, Ainscow D, Sikoski, JM; Diagnostic failures in

the multipl injured, J Trauma 1980, 20: 684-688.

5. Albrektesen SB, Thomson JL., Detection of injuries in

traumatic death. The significance of medico legal autopsy.

Forces Sci Int 1989;42:135-138.

6. Enderson BL, Stevens SL, DeBoo JM et al ; Occult

pneumothorax in blunt trauma. South Eastern Surgical

Congress Napples 1990.

7. Klinik fur anastheiologie der Johannes Gutenberg – Universitat

Mainz. Anaesthesist (Germany) Jan 1996: 45 (1), 75-87.

BOOK REVIEW

Book Title : 1) Anesthesia and co-existing Disease.

Forth Edition 2002. (Indian Print)

Authors : Robert Stoelting, Stephon F Dierdort.

Publisher : Harcourt India Pvt. Ltd. A Elsevier Science

company Price : Rs. 1475/-

The goal of this book as spelt out by the editors is to

provide the readers with ‘Current and Concise descriptions of the

pathophysiology of diseases, and the impact if any on the

management of anaesthesia’. More common conditions like

Diabetes, Hypertension, IHD, etc, which every anaesthesiologist

encounters in his day today practice, are described in wider details whereas the less common ones are discussed, based on

their unique features which have impact on anaesthetic

management.

Optimal use of illustrations, tables, figures, algorithms,

etc make the book easily understandable and more readable.

Each chapter covers the entire aspects of a topic in a concisemanner, right from the introductory information, basic sciences

to recent advances of the topic. The optimally sized and relevant

bibliography is an unique treasure of the book, catalyzing the

reader to approach the original source of information. The language

of the book is simple with consistent theme of narration throughout

the length of the book. This uniform style is quite acceptable for

every reader as every chapter in the book is finally authored bythe editors, though the contributions according to authors have

been sought by many authors.

With the new format, of presentation with newer tables

and illustrations, with distinct economical advantage of Indian

print, the book, I am sure, will attract every anaesthesiology

trainee and the practitioner.

I, on behalf of IJA, congratulate the publishers – Harcourt

India Pvt. Ltd., New Delhi, for bringing out such an excellent

tool of education at an affordable price. I recommend this book

for all the learners of anaesthesiology.

Book Title : 2) Handbook For Anesthesia and Co-existing Disease Second Edition 2002

(Indian Print).

Authors : Robert K Stoelting and Stephen F Dierdort.

Publisher : Harcourt India Pvt. Ltd. A Elsevier Science

company

Price : Rs. 275/-

Hand books play a distinct role in providing optimal

anaesthetic patient care. Irrespective of one’s seniority or

experience in the field, there is always a need for a reliable

ready reckoner, which in anaesthetic practice is in scarcity.This hand book, a companion to the widely read, ‘Anesthesia

and Co-existing Disease,’ provides rapid and accurate information

at the actual site of patient care (i.e. in OTs, ICUs etc.) if

carried in the pocket. The table format of presentation, facilitates

the quick approach to the needed information.

I appreciate and congratulate the efforts of the authors

and the publishers for providing this pocket dictionary of

anaesthesia for a modest price.

- Editor.

ghaisal train accident 2002

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