Children and the wave of destruction

The tsunami in the morning, on the 26th of December 2004, triggered by an undersea earthquake 30 km below sea floor in the Indian Ocean off Indonesia, at 06.58 hrs local time, resulted in a natural disaster of apocalyptic proportions 1 . The energy released by the earthquake is approximately 23,000 Hiroshima sized atomic bombs 1 . The giant killer waves that travelled hundreds of kilometres up to 800 km per hour across the Indian Ocean, devastated cities, and seaside communities displacing hundreds of thousands and took over 200,000 lives in a dozen countries 1 .

The objective of my presentation is to illustrate the impact of tsunami on children and their families in Galle district.This is presented in 4 stages.

• Stage1
Immediate physical and psychological impact.

• Stage2
Problems of immediate post disaster phase.
• Stage4 Impact and challenges of temporary shelters.
Why were children particularly at risk? UNICEF reported that children accounted for a large proportion of casualties.They represent 39% of the overall population in the 8 hardest hit countries 2 .Though the children can run, they were least able to withstand the floods and weren't strong enough to hold on to fixtures.Many were swept away to their deaths, while a considerably larger number were separated from their parents and family members.Others lost all their belongings.Some others were left with physical and psychological disability.It is unfortunate that the poor children of the fishing communities who are already deprived physically and socially were affected most in many different ways.
Injuries, drowning and near drowning accounted for the vast majority of mortality and morbidity experienced after tsunami.

Definition of Drowning and near drowning
After submersion in a liquid medium, suffocation and asphyxia may occur with or without pulmonary aspiration.Irreversible multi systemic injury occurs very rapidly, often leading to death 3 .Death within 24 hours of submersion is termed drowning, which may be immediate or may follow resuscitation 3 .Survival for more than 24 hours is termed near drowning, regardless of whether the victim later dies or recovers 3 .

Pathophysiology of drowning and near drowning
The principal physiological consequences of immersion injury are prolonged hypoxaemia and acidosis 3 .It affects all organs and tissues and the severity of injury depends on the duration of immersion.After initial gasping and possible aspiration, there is hyperventilation, followed by voluntary apnoea and a variable degree and duration of laryngospasm.This leads to hypoxaemia.Depending upon the degree of hypoxaemia and resultant acidosis, the person may develop cardiac arrest and tissue ischaemia 3 .Asphyxia leads to relaxation of the airway, which permits the lungs to take in water in many individuals ("wet drowning"), although most patients aspirate less than 4 ml/kg of fluid.If there is associated pulmonary aspiration, hypoxaemia and respiratory failure are exacerbated 3 .On the other hand approximately 10-20% of individuals maintain tight laryngospasm until cardiac arrest occurs and inspiratory efforts cease.These victims do not aspirate any appreciable fluid ("dry drowning") 3 .

Central Nervous System (CNS) injury
All organs can be damaged from hypoxaemia, but the brain is highly sensitive.CNS injury is now the most frequent cause of mortality and long-term morbidity 3 .Although the duration of hypoxaemia needed for irreversible CNS damage is uncertain, it is probably of the order of 3-5 minutes.Generalised neuronal death as a result of ischaemia, leads to cytotoxic cerebral oedema and increased intracranial pressure causing further CNS injury & seizures 3 .Hyperglycaemia as a result of triggered pathogenic cascades has also been implicated in exacerbating CNS injury 3 .After near drowning, children with initial blood glucose of over 300mg/dl are more likely to die or survive in a persistent vegetative state compared with normoglycaemic victims 3 .

Pulmonary aspiration
Pulmonary aspiration occurs in 85-90% of nearly drowned victims 3 .However, in the great majority of cases the amount of fluid aspirated is small.A few children may have massive aspiration, causing severe pulmonary dysfunction, fluid shifts, or electrolyte abnormalities 3 .The composition of the aspirated material too, affects the patient's clinical condition.Grossly contaminated water creates a risk of severe pulmonary infections.The gastric contents, toxic chemicals and other foreign matter can injure the lung or cause airway obstruction 3 .This was a major problem among the patients admitted after tsunami.

Seawater aspiration
Seawater is hypertonic; therefore the osmotic gradient draws interstitial and intravascular fluid into the alveoli, causing "secondary drowning" 3 .Secondary drowning is a phenomenon in which respiratory deterioration occurs as a result of pulmonary oedema between 1-72 hours of near drowning.Furthermore, seawater inactivates surfactant, resulting in an increase in alveolar surface tension and causing atelectasis of alveoli 3 .

Fluid and electrolyte alterations
Massive seawater ingestion or aspiration can lead to electrolyte changes and fluid shifts causing hypernatraemia & haemoconcentration.However, with the exception of pulmonary oedema, clinically significant fluid shifts are uncommon.Therefore substantial changes in serum electrolytes are rarely seen 3 .

Hypothermia
Near drowned patients are frequently hypothermic.Children are at an increased risk of hypothermia as a result of higher body surface area to weight, decreased subcutaneous fat and limited thermogenic capacity.The body temperature depends on water temperature, insulation provided by clothing, and the volume of aspirated water.Large volumes of water can cause rapid central cooling 4,5,6 .The implications and consequences of hypothermia in near drowned victims are the subject of significant controversy and confusion.Although severe hypothermia may rarely confer some degree of neurological protection, its pathological implications are more commonly detrimental, if not rapidly corrected.Moderate to severe hypothermia leads to progressive bradycardia and impairs myocardial contractility leading to inadequate perfusion and shock while the central respiratory centre depression results in hypoventilation and eventual apnoea 5,6,7 .Deep coma with fixed dilated pupils and absent reflexes at very low body temperatures, below 25-29 0 C may be misleading giving the false appearance of death.

Associated injuries
Falling structures and water full of swirling debris inflict crush injuries, fractures, internal organ injuries and head injuries.In a disaster of this nature, electrocution is also a possibility.

Stage I of the presentation
Immediately after tsunami, deaths and injured were brought to Teaching Hospital Karapitiya, Galle which is the premier hospital in Southern province.Teaching Hospital, Karapitiya statistics on 26.12.2004 are shown in table 4.

Table 4
No. of dead bodies brought immediately after tsunami 1300 No. of patients treated at ETU Unknown Total number of admissions 950 Devastated public and the grieving relatives carrying affected children were directed straight to the paediatric ward, without keeping any records, to relieve the workload at the 3-bed emergency treatment unit.All these patients were seen by me personally and managed under my supervision by a team of dedicated staff members of the ward, well supported by a few other hospital members.A retrospective analysis was carried out to describe the characteristics and the outcome of those drowned and neardrowned victims of Tsunami, brought to the paediatric ward.

Results and comments
Total number of children brought was 61.Out of them 45 (73.7%) were managed in the general paediatric ward while the rest, 16 (26.3%),were treated in the NICU.(Table 5) Sex distribution is shown in table 6.The male to female ratio was 1.1: 1.0.Although the exact temperature reading was not recorded under the prevailing circumstances, all our patients were cold and hypothermic on admission.Immediately after the resuscitation, re-warming measures were initiated and their body temperature was monitored closely.

Method of resuscitation
Fifty five (90%) of them needed resuscitation to restore oxygenation, ventilation and circulation with clearance of airway of vomitus and foreign material such as sand, mud and other debris.Out of the 6 (10%) patients who did not need resuscitation 3 were only hypothermic while the other 3 were hypothermic and tachypnoeic with bilateral crepitations and rhonchi.The method of resuscitation is shown in table 10.

Associated injuries
Seventeen (27.9%) had associated injuries (table 11).Major injuries noted were compound fractures, cut injuries and damaged cornea.

Respiratory complications
Twenty one had respiratory complications (Table 12).Chest x-rays were performed only on selected patients on clinical suspicion.In review of the subject of drowning and near drowning, virtually all authors recommend that patients with submersion episode, including those with a normal physical examination at the time of initial examination should be hospitalised because they are at a risk of an abrupt clinical deterioration 4,8,9,10 .In my study group, 6 (9%) of the children with near-drowning deteriorated with respiratory and neurological complications after initial recovery from the event.

Short term out come
It is documented that approximately 80% of paediatric submersion victims survive and 92% of survivors make a complete recovery 3 .In those children requiring intensive care, just over half survive neurologically intact, but approximately 13-35% die and 7-27% survive with severe brain damage 11,12 ..Factors shown to correlate with outcome include historic variables such as duration of submersion, water or patient temperature and intervention at the scene, treatment variables such as need for CPR in the emergency department, apnoea and pulselessness, depth of coma and neurological response to therapy, and laboratory variables such as pH and serum glucose 18,19,20,21 .
All 5 victims of our study group who did not respond to CPR were apnoeic with a low GCS score.Two of them did not have cardiac beat.As blood gas and blood sugar were not assayed and the temperature readings on admission was not documented we are unable to correlate the outcome of our patients.

Duration of hospital stay
This is shown in table 17.Majority (75.4%) were discharged within 3 days of admissions.The 2 children who lost both parents are from the same family and on follow up we found that they have been legally handed over to their elder sister for adoption.Only 4 children showed intense emotional reactions during hospital stay & needed professional help within first 48 hours.These children were over 5 years of age and all of them have witnessed either the mother or the father being washed away.Eighteen (29.5%) presented with late post-traumatic stress reactions and 6 of them needed specialized opinion as they showed severe stress reactions.

Limited human resources
Being early morning, on a full moon Poya day, a Sunday, day after Christmas, as one can imagine the hospital staff was not in full scale.Sudden interruption of all the possible communication facilities further compounded the situation.

Limited material resources
Interrupted power supply created an enormous difficulty in clearing the airways of vomitus or foreign material, which may result in obstruction or aspiration.Abdominal thrusts and back blows on chest were used along with large syringes to clear the airway and it's with gratitude I mention here that some doctors used the mouth as a suction apparatus.Absence of wall oxygen facility and shortage of oxygen supply was a major difficulty.Unstinting supply of medical personnel, resuscitation equipments and drugs from other wards supported us under very trying circumstances.

Bed space
Some children were resuscitated on floor, as the number of beds was inadequate to manage this magnitude of casualties admitted.To handle this mass casualty, bed space was created by prematurely discharging in-ward patients.No intensive care beds were available.Neonatal Intensive Care Unit, which cares for 8 babies, supported us by taking care of 16 of them and came to the rescue of a 12-year-old child by ventilating the child on a table.All other complicated and uncomplicated children were managed in the general paediatric ward despite the difficulties encountered.

Management of hypothermia and supply of nutrition
Fellow citizens contributed clothing and nutrients in the greatest hour of need to overcome hypothermia and starvation.

Consoling
Consoling and providing comforts to physically and mentally traumatised children; the grieving parents and the relatives were a demanding task at this very difficult time.

Problems of immediate post disaster phase
Following a devastation of this nature, disease and death rates among children under five are generally higher than for any other age group.
Maintaining the health status among the displaced children in the community became a priority to prevent outbreaks of epidemics and to prevent complications of existing medical conditions.With that in mind my paediatric team with voluntary workers visited 12 camps for displaced, within the first week of devastation.
Following problems were identified.
1. Loss of medical and immunization records.This was a major concern as the majority are not well conversant with their underlying medical condition.Unsatisfactory medical record keeping in the health sector compounded this situation.
2. The risk of worsening the existing medical condition with the loss of medical devices, inhalers and long-term medications.
3. At least 75% of child and adult survivors experienced normal stress reactions such as emotional, cognitive and physical reactions, after having witnessed and suffered this distressing and alarming experience.
4. Commonly recognized medical ailments were exacerbation of asthma, viral febrile illnesses, upper and lower respiratory tract infections, minor trauma and skin sepsis.There were no major outbreaks of diseases such as dysentery.
5. The risk of overdosage and wastage of resources.Children were inundated with unnecessary drugs with frequent visits of qualified and unqualified medical personnel without any coordination.
6.The risk of communicable diseases in overcrowded living conditions.

Mobile clinics
Mobile paediatric clinics were conducted 3 weeks after the disaster to allow better access for all affected children from areas where the infrastructure and social circumstances did not allow mobility.The common diseases identified in mobile clinics are shown in this table 20.We were much concerned about the widely distributed infant formula, which has been done without proper assessment of needs, not adhering to international guidelines.Parents who attended the clinic were asking for advice on preparation of formulae, documented in foreign languages.This would encourage mothers needlessly giving artificial feeds exposing many infants and young children to the increased risk of diarrhoea when clean water is scarce.In most complex emergencies, communicable diseases alone, or more commonly in combination with malnutrition, are the major cause of ill health and death among children.Though the WHO predicted this possibility, the disease pattern observed in these clinics and in the hospital revealed that there were no major epidemics of communicable diseases 23,24  Studies show that as many as one in three disaster survivors have severe stress symptoms that put them at risk for lasting post-traumatic stress disorder (PTSD).
What aspects of disaster are specially traumatising? 24,25e following are likely to put survivors at risk of severe stress symptoms and lasting PTSD.
• Life threatening danger or physical harm (especially to children).
• Exposure to gruesome death or human violence or destruction.
• Loss of home, valued possessions, neighbourhood, or community.
• Loss of communication with or support from close relations.
• Intense emotional demands (rescue personnel and care givers searching for possibly dying survival or interacting with bereaved family members.
• Extreme fatigue, hunger and sleep deprivation.
• Extended exposure to danger, loss, emotional and physical stray.
Which individuals are at risk for severe stress responses?
Some individuals have a higher than typical risk for severe stress symptoms and lasting PTSD including those with a history of: • Exposure to other traumas e.g.: accidents, abuse, assaults and combat.
• Chronic medical illness or psychological disorders.
• Recent or subsequent major life stressors or emotional strain (single parenting).
Disaster stress may revive memories of prior trauma and may intensify pre-existing social, economic, spiritual, psychological or medical problems.

Case report
12-year-old Nisansala, a direct victim of this disaster, was brought after near drowning and said that the tsunami swept her whole family (parents, 1 sister and 2 brothers) to their deaths.She was in a state of shock and was withdrawn and mute.She was neglecting herself and had feelings of guilt.On 28 th of December, Nisansala was able to smile after a surprised reunion with her 10 year old sister Thilini who was found among adult patients in the same hospital.Unlike Nisansala she did not show any evidence of posttraumatic stress.She was very playful and cheerful.Two days after reunion, the children were identified by their grandparents and handed over after informing the probation and childcare.
On further follow up it was confirmed that they have been legally handed over to their aunt and have recovered from post-traumatic stress.

Case report
Sithara Dilhani, a 14 year old girl from Hikkaduwa, who lost both her grandparents and all her belongings, was admitted to ward with a history of unbearable chest pain.She showed features of severe post-traumatic stress.During the hospital stay, she demonstrated the reenactment of the event by drawing pictures of the disaster.
Described above are normal reactions to extremely dangerous stressful situations where people have felt helpless.The majority of them will experience these reactions only for a short period of time.For people to get through these normal reactions and reduce further distress, basic and other practical needs were provided by local and international donor agencies.The UNICEF backed programme of psychosocial care sessions have enormously helped the children to recover.

Impact and challenges of camp settings
A further study was undertaken from 01.03.2005 to 30.04.2005 to identify health hazards, emotional and psychosocial problems among the displaced children living in temporally shelters.A pre-tested, 10-item, 2-paged, intervieweradministered questionnaire with close-ended and a few open-ended items, was employed as the data collection tool.Chief occupants of 95 tents from 10 randomly selected camping sites in Galle health administrative division were interviewed by trained medical undergraduates.Information was collected on household composition, health hazards, social and psychosocial problems, sanitation, availability of recreational centres and facilities for study and play for children.Conditions of tents and environment are based on the observations made by the interviewer.

Results and comments
Number of occupants in each tent is shown in table 23.The factors promoting communicable disease transmission interact synergistically in complex emergencies.These factors include mass population movement and resettlement in temporary locations, overcrowding, impoverishment, scarcity of safe water, poor sanitation and waste management, poor nutritional status and poor access to health care 26,27 .We can be proud that we have contained the risk of transmission of communicable diseases with appropriate and timely interventions.However it is well shown in our study that overcrowding in poorly ventilated camping sites with poor wastewater management is an important issue, which needs to be addressed to prevent epidemics of dengue and other mosquito transmitted diseases.
Research evidence supports that psychological morbidity in children after natural disasters can be high and widespread.In our study 22.3% of children suffer from stress reactions such as sleep disturbances in the form of nightmares and sleep walking and somatic complaints.These are transient in the majority and will disappear without any intervention.The medium and longterm psychological impact of the tsunami in Sri Lanka is not well understood.It is possible that a high prevalence of long-term post disaster mental health problems would be seen 28 .Fulfilling the basic health needs is an essential aspect of preventing adverse mental health consequences.The longer-term outlook for the children will depend on the resumption of ordinary life within the family and the community.These children should be adequately supported and involved in routing activities.
Out of the 10 camping sites only 4 had facilities for play and recreation.None of the guardians feared sexual abuse to their children.In contrast 100% feared a possibility of another tsunami and felt uneasy to spend the night.The majority said that there is no proper disaster plan and a warning system.

Conclusions
Never has Sri Lanka faced a natural disaster on the scale that we witnessed on the 26 th of December 2004.The time has come to face the bitter truth that we are not immune to earthquakes.Now that we know for certain that the entire region is at risk, there should be increased regional and international cooperation on mitigating impact of such disasters.A mass casualty management system should be established to respond to similar disasters with pre-established procedures for resource mobilizations, field management and hospital reception.Despite extensive damage to the country the situation has improved significantly.Sri Lanka is shifting increasingly from an acute emergency phase to one of consolidation and reconstruction.However, the situation remains acute in several areas, particularly sanitation, living conditions with unbearable heat and infrastructure.Construction of shelters with essential facilities as urgently as possible, is recommended.Nature has dealt us a sever blow; we have to come to terms with the enormity of this calamity and collectively do our best to get the country and our children back on track.
obstruction giving rise to stridor was seen in 3 patients.

Table 12
Localized and diffused crepitations as a result of pulmonary oedema and pneumonia were other significant findings.In the child in whom the foreign body of the right lung was suspected bronchoscopy was not performed to confirm the diagnosis as the facility was not available.Age distribution of the respiratory complications is shown in table13.
result of pulmonary oedema & pneumonia.Four (6.5%) others developed respiratory symptoms during the course of the day.Bronchospasm was a significant clinical manifestation noted in 17 (27.9%) of them.

Table 17
This is shown in table18.We were able to trace only 43 (75.4%)out of the 57 survived victims to determine the long-term complications.Six of them were re-admitted with late complications.

Table 20
. Information obtained from the national disaster management centre confirmed our observation.Cumulative number of communicable diseases in temporary camps in the Galle health administrative division as at 18.03.2005 is shown in table 21.