Lessons from 26/11: Triage and equitable distribution of victims is a must
From specially designated Sagari police stations to the addition of ambulances to the city’s disaster management system, the 26/11 attacks forced the government to make a number of changes. How have these panned out 13 years on? We examine three areas: civic body’s protocols, medical emergency and policing of the seas off Mumbai’s coast
When a mass disaster, like the November 26, 2008 terror attacks strikes, it is vital for the city’s administration to distribute victims across nearby hospitals without overloading any one. This requires thorough triage at the site of the disaster. These are some of the learnings from the attacks that shook the city 13 years ago, which were published in a study last year.
The study, conducted by a team of JJ hospital doctors and published in the Journal of Disaster Risk Studies in August 2020 analysed the medical response after the 26/11 Mumbai attack. The study stated that a majority of victims — 166 persons died and 238 were injured — were taken to the state-run JJ Hospital in Byculla overloading the hospital within a short period of time (271 victims were admitted to this hospital, the study said). The JJ Hospital is about 3.5 km from the main disaster sites, including the Chhatrapati Shivaji Terminus station, Leopold Cafe and Chabad House in Colaba, Trident-Oberoi in Nariman Point and the Taj Palace hotel in Apollo Bunder. Other hospitals which were closer to these sites, like the state-run St George Hospital, the state-run GT Hospital and the privately-run Bombay Hospital, received fewer victims by comparison (38, 30 and 79, respectively).
“An equitable distribution of patients is crucial in any disaster, and this did not happen during 26/11,” said Dr Dhiraj Sonawane, an orthopaedic surgeon from JJ Hospital and co-author of the study.
The study also highlighted that the city lacked the means to provide emergency medical care at a pre-hospital level. While disaster protocols were immediately activated at the hospitals, the absence of a robust on-site triage — a team of trained medics at the disaster site stabilise then shift patients to hospitals depending on the nature of their injuries and proximity of the hospital — led to an unnecessary overburdening of the hospital’s resource.
Disaster protocol at the hospital level include triage at the entry point, activating beds, operation theatres, summoning back-up doctors and other staff, among other things.
“There was an unequitable distribution of patients amongst the major public hospitals. Had there been a comprehensive disaster module, involving triage, field teams and transport teams, the number of casualties could have been reduced,” the study noted.
After the attacks, a majority of patients were brought to the hospitals by Samaritans using taxis and private vehicles. Some were even taken to the hospitals on handcarts. Since the terror strike, the most important addition to the city’s disaster preparedness has been the ambulances under the Maharashtra Emergency Medical Services (MEMS), known as the 108 ambulances. A fleet of 937 ambulances was introduced in the state in 2014. Of these 93 are in Mumbai.
The 108 ambulances are on standby for any kind of disaster — floods, fire, building collapse or terror attack — and were used extensively during the Covid pandemic in 2020. The ambulances are dispatched through an automated response mechanism based on the estimated number of people affected by a disaster. “We are linked with the BMC’s main control room, police control as well as fire control rooms,” said Dr Dnyaneshwar Shelke, chief operating officer, MEMS.
“For triaging, we label patients as yellow and red. Yellow are the ones who are injured yet stable, while red are the ones who are critical,” he said.
Additional municipal commissioner Suresh Kakani said that the civic body has a comprehensive disaster management protocol, which is refined every year. “Our protocol includes activating all the nearby public hospitals, summoning doctors residing in the area, cordoning off the area around the hospitals to allow movement of emergency vehicles and activating blood banks in the area.”
“It is an internal document, circulated among doctors and stakeholders,” he said, adding that it held the contact information of various hospitals and authorities to be contacted in case of a disaster.
The study authors however proposed a comprehensive disaster module for the city, including the formation of a central medical control committee (CMCC) comprising of experts trained in handling trauma and mass casualties. They also proposed forming field disaster teams, grading health facilities for basic and advanced trauma care and training health care staff in protocol.
In developed countries, emergency medical services during mass disasters are offered free of cost,” health activist Dr Abhijit More of not-for-profit Jan Arogya Abhiyan said. “Here, patients have to be taken to public hospitals for free treatment. There is a tendency to avoid rushing patients of mass disasters to private hospitals even if they are closer.”