The Experience of the Upu Smurd Floreasca Team during the Earthquakes in Turkey, February 2023

Abstract

Background: The recent earthquakes that occurred in Southern Turkey on the 6th of February 2023, were the most devastating earthquakes that have occurred in Turkey in the modern era. Teams of rescuers from 19 EU states quickly responded and carried out rescue missions across the affected area. This article is a report of a case series of rescues performed by the Romanian response team RO-USAR 1, with its aim being to assess the need of an internation consensus regarding immediate first-care in patients that are victims of natural or human-made catastrophes. Operations: A total of five victims were extracted alive from under the debris by our team and transported to the nearest available hospital by ambulance. A total of eight deceased victims were also extracted to facilitate access to the aforementioned alive victims. Conclusions: Quickly recognizing life-threatening situations and rapidly instating rapid fluid resuscitation is an essential step in reducing mortality in patients affected by major natural or human-made disasters. The need for an international consensus for the prehospital care of these patients is needed now more than ever in order to further ameliorate morbidity and mortality that largely occurs due to crush syndrome and its derived complications.

1. Introduction

The existence of a seismic hub known to be very active in the country of Turkey due to the intersection of three major tectonic plates, which has been a source of numerous serious earthquakes throughout history, has prompted the local authorities in Turkey to begin reconsidering the disaster management approach after recent activity. In 2009, the Disaster and Emergency Management Presidency (AFAD) was established to take the necessary measures for effective emergency management and civil protection nationwide in Turkey. In a disaster and emergency, the AFAD is the sole responsible state-run organization [1].

In the early hours of 6 February 2023, a 7.8 magnitude earthquake occurred in Southern Turkey, near the border with Syria; it had a replica of 7.5 magnitude 9 h later, situating it as fifth deadliest earthquake in the history of the Turkish state after analysis of the material damages and life loss [2].

The Romanian emergency team, named RO-USAR 1 (member of INSARAG, certified internationally since 2014) [3], responded to the calls of the Turkish state and carried out multiple rescue missions during these times of need, between 6 February and 15 February, 2023, in the Hatay province. This humanitarian mission was attended by 59 different first rescuers belonging to several first aid teams in Romania, members of UPU-SMURD Bucharest, USISU Ciolpani, DSU, IGSU, and volunteers of the Utility Canine Club. The medical team that assisted was composed of two medical doctors and two medical nurses. The team was 1 of the 255 international USAR teams and accounted for 300 lives saved during the operation [4].

This article is a report of a case series of rescues performed by the Romanian response team RO-USAR 1, with its aim being to assess the need of an internation consensus regarding immediate first-care in patients that are victims of natural or human-made catastrophes.

2. Materials and Methods

• The call for assistance—mobilization

As per protocol, 19 EU Member States (Austria, Bulgaria, Croatia, Cyprus, Czechia, Estonia, France, Germany, Greece, Hungary, Italy, Malta, Netherlands, Poland, Portugal, Romania, Slovakia, Slovenia, and Spain) together with Albania and Montenegro have offered teams in coordination with the EU’s Emergency Response Coordination Centre (ERCC) and the Turkish authorities to come to the rescue of those in need [5].

Timeline of the mission:

• Take off from Baza 90 towards Adana commercial airport: 06/02/2023 16:45.
• Touchdown in Adana: 06/02/2023 20:35.
• Leaving the airport and heading towards the AFAD regional base camp: 06/02/2023 22:30.
• Leaving the AFAD regional base camp and heading towards the allocated operations base camp: 07/02/2023 05:30.
• Arrival at the allocated operations base camp: 07/02/2023 07:29.
• Start of the first save mission: 07/02/2023 11:40.
• First victim extracted: 07/02/2023 18:29.
• Last extracted victim: 09/02/2023 00:57.

Following the international call for aid of the Turkish state, the volunteer response team assembled in an effective and efficient manner, arriving in Turkey the very same day. All resources were transported by truck and the team by bus from Adana to the base camp. An hour after arriving at the operating base, the first members of the team already left for the rescue site to assess the situation and to identify possibly alive victims trapped under the rubble of an eight-story building that completely collapsed. They used auxiliary devices (cameras, sensors, and a canine team). An hour later, the medical team arrived along with most of the medical supplies. Local civilians significantly contributed most for translation together with the local authorities (members of AKUT, police forces, etc.). The medical team acted in pairs (doctor and nurse) and in close collaboration with the non-medical first-responder teams. It is important to take into consideration the fact that the medical team acted according to the INSARAG medical guidance [6].

b.

Operations

A total of five victims were extracted alive from under the debris by our team and transported to the nearest available hospital by ambulance. A total of eight deceased victims were also extracted to facilitate access to the aforementioned alive victims [1].

c.

Scene management and extrication

Immediately after initial contact, patients were evaluated clinically by the medical team on site and an initial assessment of the gravity of the lesions was performed.

Crush syndrome is the systemic manifestation of a crush injury with organ dysfunction. It is one the most life-threatening syndromes that occurs in earthquake victims, with high morbidity and mortality amongst those affected. Cellular damage and necrosis of the muscular tissue resulting directly from crush injury releases myoglobin, potassium, phosphorus, and uric acid into the blood, and it has been shown that these can be precursors to a number of complications, including acute kidney injury (AKI), hypotension, and acidemia. More severe complications that are known to occur in these circumstances include acute respiratory distress syndrome (ARDS), cardiac dysrhythmia, and disseminated intravascular coagulation (DIC) [7,8].

Time to extrication is also known as the time period under the rubble (TPR) and depends on a variety of factors, including disaster severity, population density, building structural quality, and rescue work efficacy [9,10]. TPR is associated with earthquake morbidity and mortality, with the pediatric and geriatric populations being the highest at risk [9,10].

Resuscitation protocol was applied to the victims with an initial 1-L saline bolus (isotonic saline is the first line option in mass casualty events for volume replacement and can prevent AKI [11,12,13]) before extractions from under the debris as it is known that that inadequate fluid intake >6 h increases the risk of acute kidney injury (AKI) [11,12,13,14].

Prevention of hypothermia and analgesia by opioid boluses (e.g., Fentanyl) were also performed as it has shown to reduce mortality in these patients (more so in patients that experience rib fractures with impaired respiration) [15,16,17,18].

Another important aspect to take into account while performing initial assessments of patients is the presence of neurological traumatic injuries, which studies have shown to be the third most common injuries after musculoskeletal and abdominal injuries [19]. A postmortem examination of 51 victims of the 2011 Van earthquake revealed that visceral and cranial injuries accounted for 58.8% of all deaths, and 27.5% deaths occurred due to mechanical asphyxia [20], with traumatic brain injury (TBI) being the most common cause of on-site mortality in earthquake victims [21]. The Glasgow Coma Scale (GCS) is a widely used scale to evaluate the neurological status of patients. TBI is classified as mild (13–15), moderate (9–12), and severe (3–8), according to the GCS [22].

Rapid immobilization of the cervical spine with cervical collar and immobilization of other anatomical sites of possible instability was performed, when possible, for all the patients.

A Turkish study by Cakir et al. [23] following the 2023 earthquake has shown that the most common injuries in the pediatric population of 273 patients as diagnosed by CT scans were as follows: head injury (18.7%), followed by chest injury (15.6%), spinal injury (8.5%), pelvic fracture (7.4%), abdominal injury (3.9%), and maxillofacial fracture (2.3%).

d.

Second evaluation after extrication

The secondary survey is essential in evaluating for life-threatening injuries and to provide adequate case-related care. All patients that are alert, oriented, talking, breathing spontaneously, and moving all extremities likely do not present life-threatening injuries.

In settings with limited resources or in mass-casualty events, the goal of triage is to allocate limited medical resources to patients for whom the most benefit can be expected. Guidelines recommend treating cases with at least 50% probability of survival in the field [17,18].

3. Results

Here, we are going to briefly present the extractions of the five victims and the medical treatments administered to them, which were quickly provided in the field by the UPU SMURD team.

I.

Victim A—female, 23 years old

(a)

Time and date of first contact: 07/02/2023 at 10:30 (+30 h and 12 min from T0).

(b)

Time of the first visual contact: 11:30.

(c)

Time of the first medical aid provided: 13:00.

(d)

Time of extraction: 18:00 (+38 h from T0 and +8 h from the initial contact).

(e)

Initial diagnosis: Polytrauma by head trauma, thoracic trauma with right hemithorax subcutaneous emphysema, pelvic trauma, trauma of all four limbs, hypothermia, and hypovolemic shock.

(f)

Initial vital signs: GCS 13 (M5V4E4), vital signs impossible to assess, patient is hypothermic and in shock.

(g)

Treatment/procedures: Initially covered with a heat blanket, oxygen therapy, analgesia by opioid administration (fentanyl), intravenous hydration after peripheral venous access, cervical immobilization, and immobilization of the right leg and right arm.

(h)

Vital signs at the moment of the transport: GCS 14, core body temperature 35.6C, PA (arterial pressure) 106/58 mmHg, heart frequency 95 bpm, SpO₂ 94%.

II.

Victim B—male, 35 years old

(a)

Time and date of first contact: 07/02/2023 at 10:30 (+30 h and 12 min from T0).

(b)

Time of the first visual contact: 13:30.

(c)

Time of the first medical aid provided: 14:30.

(d)

Time of extraction: 19:00 (+39 h from T0 and +9 h from the initial contact).

(e)

Initial diagnosis: Polytrauma by head trauma, ocular trauma, thoraco-abdominal trauma, left arm and leg trauma, hypothermia, and hypovolemic shock.

(f)

Initial vital signs: GCS 14, initial vital signs not evaluable (limited access to the victim).

(g)

Treatment/procedures: Initially covered with a heat blanket, oxygen therapy, analgesia by opioid administration (fentanyl), intravenous hydration after peripheral venous access, cervical immobilization, and administration of heated crystalloid solutions (NaCl 0.9%).

(h)

Vital signs at the moment of the transport: GCS 15, core body temperature 35.8C, PA 119/81 mmHg, heart frequency 82 bpm, SpO₂ 96%.

III.

Victim C—male, 32 years old

(a)

Time and date of first contact: 07/02/2023 at 23:00 (+46 h from T0).

(b)

Time of the first visual contact: 23:30.

(c)

Time of the first medical aid provided: 08/02/2023 at 00:30.

(d)

Time of extraction: 08/02/2023 at 06:30 (+54 h from T0).

(e)

Initial diagnosis: Polytrauma with thoraco-abdominal contusion, complex left pelvic fracture by crushing complicated with compartment syndrome and gangrene.

(f)

Initial vital signs: GCS 14, hypothermic (34C), in hypovolemic shock with PAs <90 mmHg.

(g)

Treatment/procedures: The victim is stuck under the debris, especially the lower left extremity. The initial medical assessment considered the left lower extremity unrecoverable and wanted to proceed with an amputation in the field to reduce the risk of complications and to significantly reduce the extraction time. This request was rejected by the local health authorities. The medical team proceeded to place a gurney of the left lower extremity, analgesia by administration of opioids-numerous fentanyl boluses, peripheral venous access and intravenous hydration with warm crystalloid solutions.

(h)

Vital signs at the moment of the transport: core body temperature 35.7C, PA 140/84 mmHg, heart frequency 90/min, SpO₂ 94% with 6 L of O₂ administered by facial mask. The patient is deceased 24 h later at the hospital.

IV.

Victim D—male, 16 years old

(a)

Time and date of first contact: 07/02/2023 at 23:00 (+46h from T0).

(b)

Time of the first visual contact: 08/02/2023 at 11:00 (+58h from T0).

(c)

Time of the first medical aid provided: 08/02/2023 at 12:00 (+59h from T0).

(d)

Time of extraction: 09/02/2023 at 00:52 (+72h from T0).

(e)

Initial diagnosis: Polytrauma due to thoraco-abdominal contusion, complex left pelvic fracture due to crushing, and trauma of the right arm.

(f)

Initial vital signs: GCS 14, thready pulse, PAs <90 mmHg.

(g)

Treatment/procedures: Very difficult access of the patient for the medical team. Due to an aftershock of the earthquake, the initial access had to be changed as the first one became impassable. Initially covered with a heat blanket, oxygen therapy, analgesia by administration of opioids (numerous Fentanyl boluses), intravenous hydration after peripheral venous access, cervical immobilization, and administration of heated crystalloid solutions (NaCl 0.9% 4 L).

(h)

Vital signs at the moment of the transport: PA 128/70 mmHg, SpO₂ = 96% with 6 L of O₂ administered by facial mask, core body temperature 35.7 C. The patient was admitted fully conscious to the ICU unit.

V.

Victim E—male, 35 years old

(a)

Time and date of first contact: 11/02/2023 at 20:30 (+136 h from T0) (Figure 1).

(b)

Time of the first visual contact: 11/02/2023 at 21:15.

(c)

Time of the first medical aid provided: 12/02/2023 at 03:10 (+143 h from T0) (Figure 2).

(d)

Time of extraction: 12/02/2023 at 08:30 (+148 h from T0).

(e)

Initial diagnosis: Polytrauma with minor head trauma, crush trauma of the lower right extremity, and lower left leg luxation.

(f)

Initial vital signs: GCS 14, thready pulse with a heart frequency of 60 bpm, hypothermic 34.6 C, PA not obtainable.

(g)

Treatment/procedures: Intravenous hydration after peripheral venous access, cervical immobilization, administration of heated crystalloid solutions (NaCl 0.9% 4 L), oxygen by facial mask up to 6 L per minute, analgesia by administration of opioids before and during the extraction and the mobilization of the trapped lower extremities by fentanyl boluses initially then tramadol.

(h)

Vital signs at the moment of the transport: core body temperature 35.2 C, PA 117/54 mmHg, heart frequency of 95/min, SpO₂ 97% with 6 L of O₂ administered by facial mask.

Figure 1. Initial contact and extrication planning.

Figure 1. Initial contact and extrication planning.

Figure 2. Difficult access to the patient and initial resuscitation by heated blanket and IV crystalloid.

Figure 2. Difficult access to the patient and initial resuscitation by heated blanket and IV crystalloid.

A total of five victims were extracted alive from under the ruble (

Table 1. Initial statuses of the victims and vital sign reevaluation after initial resuscitation.

	Time Period under Ruble (TPR) (hours)	Extrication Duration (hours)	Initial Systolic Arterial Pression (mmHg)	Initial GCS (Glasgow Coma Scale)	Hypothermia (Yes/No)	Crush Syndrome Suspected (Yes/No)	Neurological Injury Suspected (Yes/No)	GCS after Extrication	Arterial Pressure after Extrication and IV NaCl Resuscitation (Systolic/Diastolic, mmHg)
Victim A	38	8	N/A	13	Yes	Yes	Yes	14	106/58
Victim B	39	9	N/A	14	Yes	Yes	Yes	15	119/81
Victim C	54	8	<90 mmHg	14	Yes	Yes	Yes	15	140/84
Victim D	72	14	<90 mmHg	14	Yes	Yes	No	15	128/70
Victim E	148	12	N/A	14	Yes	Yes	Yes	14	117/54

). The mean time period under the ruble was 70.2 h, with a mean extraction time of 10.2 h. The patients were all hypotensive, hypothermic, and dehydrated, with multiple injuries visible (head injury in four out of five patients, suspected crush syndrome suspected in five out of five patients). Intravenous fluid resuscitation was administered to prevent AKI and organ hypoperfusion; temperature regulation was performed for all the patients equally using heated blankets and cervical stabilization. All patients were transported alive to regional hospitals with normal arterial blood pressure without vasopressor, with a mean GCS score of 14. One patient died in the following hours. Sadly, we were unable to obtain any follow-up for the rest of the patients.

In addition to the medical care provided to the victims of the earthquake, another important role of the medical team provided by UPU SMURD was to treat the ailments of the people who participated in the rescue operations, especially the firefighters and even the other members of the medical staff. The common injuries seen in the group were those of lower back pain (treated with AINS and myorelaxants n = 9), anxiety (as to be expected from working in these specific situations) (n = 4), respiratory infections (n = 3), and other traumatic injuries that required suturing, wound care, and dressing (n = 2).

4. Discussion

The prehospital process, i.e., the first responders’ phase that includes victim identification, extrication, and all the medical care provided before, during, and after extrication has shown to decrease mortality if performed in a timely fashion. In major earthquakes, almost 20% of all deaths occur shortly after victim extrication; this situation is known as “rescue death”, i.e., sudden hemodynamic deterioration and death within 20 min of the rescue of patients that were stable before mobilization from underneath the debris, with reperfusion of a severely traumatized extremity believed to lead to systemic circulation of tissue breakdown products, resulting in life-threatening cardiac dysrhythmias [24,25,26,27].

The incidence of crush syndrome is reported to be 2–5% among earthquake victims and 30–50% among patients with post-traumatic rhabdomyolysis [28]. A study by Onan et al. [29], that evaluated the mortality factors in crush syndrome patients affected by the 2023 earthquakes, found the incidence of crush syndrome to be 20.9% among all earthquake victims. One of the risk factors associated with a high mortality was found to be initial hypotension, and although it is frequently reported in shock, it has not been previously reported in relation to crush syndrome; this further reinforces the idea that initial fluid resuscitation is an essential step in reducing mortality.

Care in this setting is dangerous and requires specialized training. Dust, extreme temperatures, uncontained fires, hazardous materials and gases, and risk of explosions pose significant threats to rescuer safety. Heavily damaged buildings are at risk of secondary collapse and may further endanger victims and rescuers alike, leading to additional casualties. Rescuers should be trained in extrication and providing patient care while donning personal protective equipment [16].

In all, in order to achieve maximum efficacy in proving the best care for these patients, we must focus on the following factors: rapid extrication of victims caught under debris, which has been shown to reduce mortality; gaining intravenous access to provide intravenous resuscitation and intravenous antalgic treatment, which has been shown to drastically reduce mortality by reducing the gravity of AKI in the context of crush syndrome; prevention of hypothermia; better coordination among local teams so that all patients are directed to the most suitable center in area.

4.1. Logistical Problems Encountered

As with any hastily assembled intervention group, some difficulties are to be expected, notably logistical problems. Some examples are listed here:

• During the mission, medical staff had accommodation in a tent that also served as a warehouse for medical supplies, with heating provided by gas-powered heaters (as the temperatures in Turkey reach freezing during the night). Depending on the direction and intensity of the wind, the smoke emitted by these heaters can enter the living spaces and could have posed serious issues (CO intoxication, asthma attacks, etc.).
• Basic hygiene was very limited during the first hours, i.e., there was no real bathroom on site, and no running hot water.
• Another issue was the lack of adequate equipment provided to the medical team. Considering the level of dust and cadaveric decomposition, adequate protective masks should have been mandatory; also, since the temperatures were very low at that time in Turkey, basic first intervention suits are not suitable for the working conditions, and led to an increase in the fatigue of the medical team.
• No internet access in the first 72 h.

4.2. Post-Mission Discussion

The overall experience of the UPU SMURD team in the rescue missions following the earthquakes in the Hatay province of Turkey in February 2023 was a positive one, having provided immediate care for numerous victims and saving five victims who were trapped under the rubble for more than 24 h.

The presence of a medical team (medical doctors and nurses) has proven to be essential by playing a vital role in the extraction process by providing immediate care (resuscitation); secondly, they were able to provide analgesic drugs, facilitating the movement of the victims. Additionally, they were able to provide insights into how and when to mobilize the victims and also how and when to speed up the extraction process based on their medical assessments.

There were also some negative aspects that need to be addressed for future efforts; in particular, a mobile center that can function as a mobile home with bedrooms and bathrooms should be organized and delivered before or some hours after the arrival of a medical team on site.

5. Conclusions

Quickly recognizing life-threatening situations and rapidly initiating rapid fluid resuscitation is an essential step in reducing mortality in patients affected by major natural or human-made disasters. The need for an international consensus on prehospital care for these patients is needed now more than ever in order to further ameliorate morbidity and mortality rates. The presence of a medical team on the ground providing immediate medical care to the victims of any calamity (natural or not) has proven to be essential; this can be seen in the experience of the UPU SMURD team during the earthquakes in Hatay province, Turkey. The medical team provided necessary advantages for the first responders by improving the survivability of the victims with the medical treatments provided, as well as by providing care and treatment to the first responders.