Never ending trouble of humanity. When The Earthquake Hits How We Can Survive In Poor Constructed Buildings? Suggestions Concerning Reduction of Mortality.

Never ending trouble of Never ending trouble of humanityhumanity

When The Earthquake Hits How When The Earthquake Hits How We Can Survive In Poor We Can Survive In Poor Constructed Buildings?Constructed Buildings?

Suggestions Concerning Reduction of Mortality and Suggestions Concerning Reduction of Mortality and MorbidityMorbidity

M.Ferudun ÇELIKMEN¹M.Ferudun ÇELIKMEN¹, Kurtulus ACIKSARI², Sezgin SARIKAYA¹, Derya , Kurtulus ACIKSARI², Sezgin SARIKAYA¹, Derya ABUSKAABUSKA33, Pınar TURA¹, Ali KANDEMİR¹, Halil DOGAN, Pınar TURA¹, Ali KANDEMİR¹, Halil DOGAN44, Mustafa YAZICIOGLU, Mustafa YAZICIOGLU44, ,

D. Niyazi OZUCELIKD. Niyazi OZUCELIK55. .

¹ İstanbul Yeditepe University, Faculty of Medicine, Emergency Medicine Department, İstanbul 2 İstanbul Bilim University, Faculty of Medicine, Emergency Medicine Department, İstanbul

3 Emergency and Disaster Medical Services, Health Directorate of İstanbul, İstanbul4 Bakirkoy Dr. Sadi Konuk Research and Training Hospital, Emergency Medicine Department, Istanbul

5 İstanbul University Faculty of Health Sciences, İstanbul

²

IntroductionIntroduction Main survival factors in the post-disaster period Main survival factors in the post-disaster period

are prevention from injuries as well as detecting are prevention from injuries as well as detecting the location of the survivors and the rescued. The the location of the survivors and the rescued. The reality of the situation of persons who lost their reality of the situation of persons who lost their lives in such traps, the severely injured, and the lives in such traps, the severely injured, and the ones who survived must be analyzed. ones who survived must be analyzed.

Rational prevention methods against possible Rational prevention methods against possible crush injuries due to collapsing buildings have crush injuries due to collapsing buildings have been considered in the light of the field and been considered in the light of the field and simulation experience we gained and suggestions simulation experience we gained and suggestions have been presented to reduce mortality and have been presented to reduce mortality and morbidity. Our work has been conducted with the morbidity. Our work has been conducted with the aid of medicine based on proof, appropriate aid of medicine based on proof, appropriate observation as well as sampling and experimental observation as well as sampling and experimental methodsmethods..

AimAim Action plans of developed countries with higher Action plans of developed countries with higher

building standards, which construct buildings that building standards, which construct buildings that would not collapse in case of earthquakes and similar would not collapse in case of earthquakes and similar disasters, have been adopted one to one by disasters, have been adopted one to one by underdeveloped and developing countries without underdeveloped and developing countries without questioning against what and why these should be questioning against what and why these should be applied.applied.

A global approach concerning worst case scenario A global approach concerning worst case scenario led by earthquakes has been proposed taking into led by earthquakes has been proposed taking into consideration the different models of behavior in consideration the different models of behavior in different countries and societies to increase the different countries and societies to increase the chance of survival to a maximum and to reduce chance of survival to a maximum and to reduce injuries to a minimum level. Due to unlimited injuries to a minimum level. Due to unlimited possibilities of travelling nowadays, it is not possible possibilities of travelling nowadays, it is not possible to estimate the place, the country or the to estimate the place, the country or the circumstances under which a person could circumstances under which a person could experience a disaster.experience a disaster.

Materials and Methods 1Materials and Methods 1

Moreover the situation and location of Moreover the situation and location of the rescued persons and the survivors the rescued persons and the survivors during and after the disaster have during and after the disaster have been analysed by search and rescue been analysed by search and rescue teams in the between 1992-1999 years teams in the between 1992-1999 years in Turkey and other countries of the in Turkey and other countries of the world dealing with mass disasters led world dealing with mass disasters led by earthquakes which result in crush by earthquakes which result in crush injuries injuries

On site

EarthquakesEarthquakes in the previous years in Turkey and other in the previous years in Turkey and other countries, where we personally joined the post-disaster countries, where we personally joined the post-disaster

search and rescue operations, their magnitudes and figures search and rescue operations, their magnitudes and figures of casualties are shown of casualties are shown

DateDate TimeTime LocationLocation MagnituMagnitu..

MortaliMortalityty

MorbidMorbidiittyy

RescuedRescued

13.03.19913.03.19922

19:1819:18 ErzincanErzincan R:6.8R:6.8 653653 3.5003.500 33

01.10.19901.10.199

55

17:5717:57 DinarDinar R:6.1R:6.1 101101 260260 22

17.08.19917.08.1999 9

03:0203:02 MarmaraMarmara R:7.4R:7.4 17.84017.840 43.95343.953 118118

07.09.19907.09.1999 9

14:5614:56 AthensAthens R:5.9R:5.9 143143 2.0002.000 22

21.09.19921.09.1999 9

17:4717:47 TaiwanTaiwan R:7.6R:7.6 2.1612.161 8.7368.736 11

12.11.19912.11.1999 9

18:4818:48 DüzceDüzce R:7.2R:7.2 848848 4.9484.948 1212

TOTALTOTAL 21.74621.746 63.39763.397 138138

One of their approaches was to involve One of their approaches was to involve schools. Teachers in selected cities were schools. Teachers in selected cities were encouraged to conduct air raid drills where encouraged to conduct air raid drills where they would suddenly yell, "Drop!" and they would suddenly yell, "Drop!" and students were expected to kneel down under students were expected to kneel down under their desks with their hands clutched around their desks with their hands clutched around their heads and necks. Some schools even their heads and necks. Some schools even distributed metal "dog tags," like those worn distributed metal "dog tags," like those worn by World War II soldiers, so that the bodies of by World War II soldiers, so that the bodies of students could be identified after an attack. students could be identified after an attack.

The advice to "duck and cover" holds well in many situations where structural destabilization or debris may be expected, such as during an earthquake or tornado. At a sufficient distance from a nuclear explosion, the blast wave would produce similar results and ducking and covering would perhaps prove.

Ducking and covering would also reduce Ducking and covering would also reduce exposure to the gamma rays. Since they are exposure to the gamma rays. Since they are mostly emitted in a straight line, people on mostly emitted in a straight line, people on the ground will have more chance to have the ground will have more chance to have obstacles such as building foundations, cars, obstacles such as building foundations, cars, etc. between them and the source of etc. between them and the source of radiation. The technique offers a small radiation. The technique offers a small protection against protection against fallout—people standing up —people standing up could receive a large, possibly lethal, dose of could receive a large, possibly lethal, dose of radiation, while people protected will receive radiation, while people protected will receive less of itless of it..

Duck and Cover!..Duck and Cover!..

Drop, Cover and Hold Drop, Cover and Hold OnOn!..!..

It is after all, a first response It is after all, a first response countermeasure only. In much the countermeasure only. In much the same way that 'Drop, Cover and same way that 'Drop, Cover and Hold On' is during an earthquake, Hold On' is during an earthquake, with the advice having little utility with the advice having little utility once the earthquake has passed, and once the earthquake has passed, and possibly other looming dangers like possibly other looming dangers like a a tsunami may be approaching may be approaching..

This victim who died perhaps could have still This victim who died perhaps could have still been alive if he had taken the been alive if he had taken the fetusfetus position in position in

the same gap with a sufficient height.the same gap with a sufficient height.

This victim perhaps could This victim perhaps could have still been alive if he had have still been alive if he had taken the taken the fetusfetus position in position in the same gap with a the same gap with a sufficient height.sufficient height.

Floor and ceiling even get close allow some space to survive if you get Floor and ceiling even get close allow some space to survive if you get proper position.. proper position..

Materials and Methods 2Materials and Methods 2 Simulation

SimulationSimulation

As the rubble was removed and approaching As the rubble was removed and approaching tunnels were established, the assessment of the tunnels were established, the assessment of the damage on the dummies showed that the ones damage on the dummies showed that the ones placed (horizontally) prone,supine position or placed (horizontally) prone,supine position or kneeling were completely crushed. Only 2 of kneeling were completely crushed. Only 2 of the dummies reduced in size by folding the the dummies reduced in size by folding the extremities (imitated fetal posture) and placed extremities (imitated fetal posture) and placed in a horizontal side position between beds full in a horizontal side position between beds full of books underneath and desks in cage of books underneath and desks in cage construction showed crush injuries on leg construction showed crush injuries on leg pieces after being hurled; others did not show pieces after being hurled; others did not show any damage.any damage.

DiscussionDiscussion Main aim of the prevention from crush Main aim of the prevention from crush

injuries must be minimising the risk of injuries must be minimising the risk of injuries while maximizing the chance of injuries while maximizing the chance of survival. This can be achieved by survival. This can be achieved by reducing injury targets as much as reducing injury targets as much as possible. possible.

The main factor decreasing the rate of The main factor decreasing the rate of mortality and morbidity in massive mortality and morbidity in massive disasters such as earthquakes is clearly disasters such as earthquakes is clearly the construction of robust buildings on the construction of robust buildings on safe ground. However the last chance in safe ground. However the last chance in every situation should be exploited by every situation should be exploited by doing the proper action within seconds. doing the proper action within seconds.

lying down in the fetus position lying down in the fetus position next to the relatively safety placesnext to the relatively safety places

Lying down in the fetus position next to the relatively safety places

Households,furnitures that can be crushed but not completely destroyed

Lying down on the

ground beside the cars also

increase survivalchance

Fetus position..Minimise targeting ..Fetus position..Minimise targeting ..You need only one bottle of water and cellphone!You need only one bottle of water and cellphone!(usually both should be with you even in the (usually both should be with you even in the night time…)night time…)

Results Results

Individual emergency action plans of Individual emergency action plans of developed countries with much higher developed countries with much higher urbanisation and building standards urbanisation and building standards which construct buildings that would not which construct buildings that would not collapse in case of earthquakes and collapse in case of earthquakes and similar similar disasters comprise more the disasters comprise more the cases caused by smashing objects rather cases caused by smashing objects rather than collapsing buildings. These plans than collapsing buildings. These plans are adopted one to one by countries with are adopted one to one by countries with lower standards.lower standards.

Results Results Action plans concerning disasters such as Action plans concerning disasters such as

earthquakes recommended by relevant earthquakes recommended by relevant authorities of developed countries such as authorities of developed countries such as USA and Japan comprise more an approach to USA and Japan comprise more an approach to the protection of individuals from smashing the protection of individuals from smashing objects during an earthquake such as going objects during an earthquake such as going under a table, rather than the prevention under a table, rather than the prevention from crush injuriesfrom crush injuries..

It is bitter reality that an earthquake of the It is bitter reality that an earthquake of the same magnitude and duration causing nearly same magnitude and duration causing nearly no casualties in developed countries can lead no casualties in developed countries can lead to thousands of deaths and physical to thousands of deaths and physical disabilities due to crush injuries in disabilities due to crush injuries in underdeveloped countries.underdeveloped countries.

Suggestions 1Suggestions 1

Minimizing target Minimizing target as much as possible as much as possible by staying in the by staying in the fetusfetus position position in in possible gaps formed by horizontal possible gaps formed by horizontal layers, between vertical elements of the layers, between vertical elements of the building, next to furniture that can be building, next to furniture that can be crushed but not completely destroyed crushed but not completely destroyed is a fact observed by many rescued or is a fact observed by many rescued or surviving persons. Dummies that were surviving persons. Dummies that were made compact show the least damagemade compact show the least damage. .

Suggestions 2Suggestions 2 Being under rubble combined with winter Being under rubble combined with winter

conditions while waiting to be rescued can conditions while waiting to be rescued can lead to lead to hypothermiahypothermia which can also be which can also be lethallethal..

The best prevention against hypothermia is The best prevention against hypothermia is again minimizing the body surface as much again minimizing the body surface as much as possible and taking the as possible and taking the fetusfetus position position..

This position just like the This position just like the recovery position recovery position will help to avoid lethal situations such as will help to avoid lethal situations such as asphyxia secondary to the aspirationasphyxia secondary to the aspiration which which can occur due to the loss of consciousness can occur due to the loss of consciousness in casein case of of lying for a long period of time lying for a long period of time. .

Suggestions 3Suggestions 3

The best method of staying alive with theThe best method of staying alive with the basal metabolic basal metabolic rate is to be in a rate is to be in a permanent state of sleeping. Many permanent state of sleeping. Many mammals manage to sleep in the mammals manage to sleep in the fetusfetus position for months during the winter position for months during the winter without supplying any nutrition or liquid without supplying any nutrition or liquid to their body (to their body (hibernationhibernation).).

In case of collapsing buildings the first In case of collapsing buildings the first fatal blow fatal blow will be on the will be on the head and neck head and neck region if the region if the ‘‘drop, cover and hold ondrop, cover and hold on’’ kneeling position is takenkneeling position is taken. .

Suggestions 4Suggestions 4

A survival gap for the A survival gap for the fetal posturefetal posture must must be at least be at least hip heighthip height, i.e. an average , i.e. an average height of height of 40 cm 40 cm would be sufficient. The would be sufficient. The height required for the ‘height required for the ‘drop, cover and drop, cover and hold onhold on’ position is minimum twice as ’ position is minimum twice as much much ..This height of approximately This height of approximately 1m1m is is even more than the thickness of carrier even more than the thickness of carrier elements such as columns and beams elements such as columns and beams which help to form survival gaps between which help to form survival gaps between horizontal layers in case of ‘horizontal layers in case of ‘pancakepancake’.’.

Suggestions 5Suggestions 5

Staying in Staying in kneeling position kneeling position for a long for a long time makes it impossible to stay alive time makes it impossible to stay alive exposing the lower extremities to exposing the lower extremities to pressure as well as due to the pressure as well as due to the congestioncongestion in thoracic and splanchnic in thoracic and splanchnic areas whereas in the areas whereas in the fetusfetus position position, just , just as in the as in the recovery positionrecovery position, the , the functions of cardiac and respiratory functions of cardiac and respiratory system can be preserved for a longer system can be preserved for a longer timetime. .

Suggestions 6Suggestions 6

Early access of the rescued with crush injuries Early access of the rescued with crush injuries to to dialysisdialysis is the most significant medical is the most significant medical approach concerning mortality and morbidity. approach concerning mortality and morbidity. Another very important survival factor before Another very important survival factor before the dialysis is the dialysis is maintaining the function of maintaining the function of kidneys kidneys while waiting for rescue. It is quite while waiting for rescue. It is quite obvious that the obvious that the protection of at least one protection of at least one kidneykidney can be achieved in the embryonic can be achieved in the embryonic position between horizontal elements of less position between horizontal elements of less than 40 – 50 cm height compared to a face than 40 – 50 cm height compared to a face down or up horizontal positiondown or up horizontal position. .

Suggestions 7Suggestions 7 Staying in the compact Staying in the compact fetusfetus side position side position

with knees pulled towards the abdomen, with knees pulled towards the abdomen, the the rubble can be pushed by hands and feet rubble can be pushed by hands and feet to expand to expand the necessary survival gap.the necessary survival gap.

It is obvious that for persons living in high It is obvious that for persons living in high rise buildings objects such as tables, chairs rise buildings objects such as tables, chairs with small surfaces and contact with the with small surfaces and contact with the floor are not stable and change position floor are not stable and change position easily in earthquakes with high magnitudes. easily in earthquakes with high magnitudes. Looking for protection under such objects is Looking for protection under such objects is not much different than not much different than expecting shelter expecting shelter from an umbrella during a severe stormfrom an umbrella during a severe storm..

Suggestions 8Suggestions 8

The priority in search and rescue The priority in search and rescue operations in case of ‘pancake’ buildings operations in case of ‘pancake’ buildings is to look for is to look for survivors in bulging areassurvivors in bulging areas. In . In 284 cases survivors rescued by our SAR 284 cases survivors rescued by our SAR teams in search and rescue operations in teams in search and rescue operations in Turkey and other countries until now Turkey and other countries until now (personal participation in 138 cases with (personal participation in 138 cases with SAR activities) we can see persons who SAR activities) we can see persons who survived due to survived due to fetusfetus or similar positions or similar positions rescued from rescued from these these confined spacesconfined spaces..

Suggestions 9Suggestions 9

AsphyxiaAsphyxia is one of the mortality is one of the mortality reasons for those under rubble reasons for those under rubble ..In In the horizontal side position it is the horizontal side position it is possible to possible to protect the mouth and protect the mouth and the nose from rubble by using the the nose from rubble by using the underarms and handsunderarms and hands and in this and in this way to expand the respiratory area. way to expand the respiratory area.

Suggestions 10Suggestions 10

It is of great importance to protect the upper It is of great importance to protect the upper and lower extremities in case of long lasting and lower extremities in case of long lasting rescue operations to lift the rubble and get the rescue operations to lift the rubble and get the survivors out survivors out ..To prevent a crush syndromeTo prevent a crush syndrome the the ıv linesıv lines must be must be establishestablish as soon as the as soon as the rescuers find the survivors using cheap, rescuers find the survivors using cheap, potassium-free, easily accessible fluids such as potassium-free, easily accessible fluids such as saline solutions to stabilize the positive liquid saline solutions to stabilize the positive liquid balancebalance..

The The fetusfetus position with its compact state position with its compact state increases the chance of protecting extremitiesincreases the chance of protecting extremities..

Developing and undeveloped countries main eartquake problem is totally Developing and undeveloped countries main eartquake problem is totally collapsed buildings secondary to the poor construction and mis choosen collapsed buildings secondary to the poor construction and mis choosen landscape for erecting buildings!landscape for erecting buildings!

Dozens of Dozens of mythsmyths

If indoorsIf indoors DROPDROP to the ground; take to the ground; take COVERCOVER by getting by getting

under a sturdy table or other piece of furniture; under a sturdy table or other piece of furniture; and and HOLD ONHOLD ON until the shaking stops. If there until the shaking stops. If there isn’t a table or desk near you, cover your face and isn’t a table or desk near you, cover your face and head with your arms and crouch in an inside head with your arms and crouch in an inside corner of the building. corner of the building.

Stay away from glass, windows, outside doors and Stay away from glass, windows, outside doors and walls, and anything that could fall, such as lighting walls, and anything that could fall, such as lighting fixtures or furniture. fixtures or furniture.

Stay in bed if you are there when the Stay in bed if you are there when the earthquake strikes. Hold on and protect earthquake strikes. Hold on and protect your head with a pillow, unless you are your head with a pillow, unless you are under a heavy light fixture that could fall. In under a heavy light fixture that could fall. In that case, move to the nearest safe place!!!? that case, move to the nearest safe place!!!?

Stay in bed if you are there when the earthquake strikes. Hold on and protect your head with a pillow, unless you are under a heavy light fixture that could fall !!!!!…

Stay in bed!!…… Hold on and protect your head with a pillow!!.

Earhquake packs!!Earhquake packs!! Another mit ..Time elapsing for survive..Another mit ..Time elapsing for survive.. Originally coming from subway culture of Originally coming from subway culture of London bombing and adopted during cold London bombing and adopted during cold war!war! There is enough food etc if you can survive,even There is enough food etc if you can survive,even in the poorist country!in the poorist country!

Shelter paranoia!!

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There is nothing There is nothing comparable with the saving comparable with the saving

liveslives

There is nothing comparable with the There is nothing comparable with the saving livessaving lives