Dr. Jahanzeb Effendi
The anger, frustration, disappointment, and rage cannot be expressed in words. The dastardly terrorist attack on 16th Dec, 2014, targeting the students and staff of the Army Public School on Warsak Road , Peshawar has shocked not just Pakistan, but the entire world.
It is time Pakistan realizes that they no longer have the luxury of fighting conventional warfare. War is no longer limited to the battlefield. It has come into the streets, neighborhoods, markets, schools and towns of Pakistan. And it becomes incredibly important to protect themselves from the death and destruction inflicted by the terrorists.
With the threat of retaliation attacks on other schools and as schools begin to reopen after the winter break, it is time to protect our children from any unseen eventuality.
Preparedness and planning to deal with disasters is crucial to protect life and properties of the people. Every individual must know the essentials of first response to medical emergencies and basic trauma care. Every institution, be it a school, college, university, hospital, corporate office, factory etc. should have a disaster management plan and anticipate a mass casualty incident, especially during festivals, processions in crowded places, major shopping weekends and religious and political gatherings.
The Disaster Management Plan should be made especially, for each and every school and be enforced and implemented in the form of regular drills. These drills should be followed a debriefing session and relevant changes and alterations should be made to the disaster plan. No disaster plan is perfect, only regular drills insure that loopholes are plugged. And the more the disaster plan is drilled, the finer it becomes.
Disaster Planning and Management has it’s A, B, C, D & E.
C: Coordination & Communication
The most important prerequisite is to anticipate a disaster anytime. Anticipation is necessary for adequate preparedness, preparation and backup. CCTV cameras should be installed around the premises and adequate monitoring done. Internal security should be beefed up, especially during opening and closing time. Coordination between all stake holders, in case of an unexpected emergency, is vital for effective disaster management. This includes children, parents, law enforcement agencies, rescue workers, bomb disposal squads and fire brigade. Communication includes adequate warning systems e.g. alarm bells as well as communication between victims as and with law enforcement and rescue workers during the disaster. For schools, an internal speaker system in all classes or an emergency bell that can signify the nature of emergency is mandatory. Students should be familiar with the bells and be drilled regularly to act accordingly. Dangers are identified in regard to natural vs. man-made disasters such as suicide bombing and homicide. Finally, any equipment that will be vital for communication or emergency first aid as well as communication and escape is stored in an accessible location in anticipation of the disaster.
An evacuation plan must be designed according to the number of students, staff and faculty and the present emergency exits. The role of all individuals in the disaster plan is defined before, hence no time is wasted. Teachers should be given the responsibility of their classes and should lead in cases of emergency.
The United States Homeland Security and the City of Houston Mayor’s Office of Public Safety, in one of their public safety campaign, released an awareness video called “RUN-HIDE-FIGHT. Surviving an Active Shooter Event.”
This video, which is also hosted on the official FBI website, demonstrates the steps victims should take in the event of an armed attacker/s in the building. The victims are instructed to first find an escape route in case they hear ‘pops’ or gun shots in the distance. This requires prior knowledge of emergency exits and evacuation. Others should be warned and taken along to the nearest exit. If the attacker is close and evacuation is not possible then the victims should hide. This has been explained under ‘lock down’ below. Finally, if it is not possible to run or hide, then the victims should consider fighting – primarily by disarming the attacker with any equipment they can find, like chairs or furniture etc. The video can be accessed at the following link:
The concept of Lock Down and Lock Out should be implemented and especially drilled in schools and offices to protect the students, staff, faculty and employees from armed attackers and terrorists. The lock down command during an emergency signifies immediate seeking of shelter from an armed individual/s inside the premises (when no information of attacker’s whereabouts is known). For children in schools, this would refer to finding an immediate shelter and shutting all doors that could lead to the class room. They should be locked and in case they are unable to lock, doors should be barricaded with furniture to prevent anyone from entering the classroom. Blinds or curtains of windows should be drawn and lights and fans are turned off. The students should not huddle in one corner and instead spread themselves and keep maximum distance from doors and windows. All students are instructed to put their cell phones on silent and wait in crouching positions till they hear from police or school authorities.
The Lock Out code is activated when a suspected danger is out of the premises of the schools but within the vicinity. All entry and exit points are thus sealed and no one is allowed to leave the building. A headcount is conducted and people only leave when the situation is under control.
The Disaster plan for an institution e.g. a school should not just be restricted to the school itself. Instead, the school should make efforts of identifying police stations, military stations, hospitals, clinics, volunteers, fire department and emergency medical services in the vicinity. These institutions should be informed about the student strength of the school and involved in the disaster management plan. During disaster drills, police, ambulances, fire staff and other stake holders should be expected to respond and alerted as in real life situation.
With the unexpected nature of such attacks, all hospitals of Pakistan should also have a disaster plan ready. Emergency medicine staff, residents, nurses, casualty medical officers, volunteers from concerned organizations, security staff and housekeeping staff, should all be part of disaster plan. Drills should be conducted regularly and the plan altered accordingly. Volunteers from areas surrounding the hospital as well as scouts should be included in the planning stage. They should be briefed and trained on securing scene safety and mob management.
A central command and control system (C&C) should be in place in all cities. A centralized number like 911 should be established that links to all police, military and rescue and ambulance networks. This number should be publicized so that every individual and child knows where to call in case of an emergency or disaster.
The C & C ensures that rescuers and ambulances do not choke the closest hospitals with dead and wounded patients, as was witnessed in Gurkhi Trust Hospital in Lahore and Patel Hospital in Karachi after the Wagah Border bombing and Abbas Town bombing, respectively. In both these disasters, the majority of the victims, dead and wounded, were rushed to the closest hospitals, which did not have the capacity and staff strength to deal with this disaster. And as a result many critical patients who needed immediate attention were neglected.
The command and control center should direct and coordinate with the ambulance networks by means of radio to distribute victims according to severity of their wounds and availability of beds in the trauma bay. This system is called triage.
Victims should be triaged and sent to the closest trauma center if they are tagged RED (immediate), YELLOW (delayed wounded) to the next closest hospital, GREEN (walking wounded) to peripheral clinics and hospitals and BLACK (expectant) to the morgues. This will prevent the overburdening of one trauma center during a mass casualty incident in any city. Training first responders in performing on site triage will be an excellent intervention to help save lives as the first hour of trauma management is critical and rapid assessment and resuscitation of victims of trauma saves lives in the ‘golden hour.’ This golden hour principle especially saves lives of the most critical patients.
Terrorists can strike at any place and at unpredictable time. All major hospitals should put aside their professional rivalries and maintain a ‘hotline’ for coordination and distribution of victims. The Casualty Medical Officers and all emergency medical staff need to be trained in primary trauma care (PTC) especially dealing with gunshot wounds and bomb blast injuries. The accident and emergency units of all hospitals should also have ’emergency carts’ and ‘disaster kits’ in bulk quantity stored in the emergency unit in anticipation of a disaster. Training of security staff and volunteers in mobilization of internal security, media management and handling of angry or charged relatives should be practiced, reinforced and drilled regularly.
A number of organizations are working in the country to train hospital leaders and staff in disaster management in Pakistan. However, there is yet a lack of initiative taken by the hospitals in the public and private sectors. Many outstanding organizations are training individuals to volunteer as first responders in case of a disaster and help save human lives.
Without institutional disaster planning and pre-hospital and hospital disaster plans, drills, debriefing and editing of the plans, we will not be able to reduce the burden of death and disability due to trauma and disasters in Pakistan. The security forces should play their active part in protecting us and the media should act more responsibly in their coverage of disasters.
As it has been said repeatedly before – the Peshawar Army Public School tragedy on the 16th of December 2014, is the 9/11 of Pakistan, it is time the people rise and act to prevent more loss of life in the future. Safe environments and safe schooling is the birthright of every Pakistani child.
Pakistanis are a strong nation, and with these heinous attacks on humanity, may be destroyed temporarily, but they will never be defeated.
Our prayers are with the young heroes of Pakistan today. May they always rest in peace.
Pakistan Zindabad Pakistan Pa’indabad!
Dr. Jahanzeb Effendi is a young doctor, First Responder and Co-founder of the First Response Initiative of Pakistan, FRIP. He is training doctors, medical students and the general public to become first responders. He also trains hospital emergency doctors and staff in disaster management and primary trauma care. His research interest is in trauma and injury patterns due to bomb blasts in Pakistan. He aspires to be a Cardiac & Lung Transplant Surgeon and plans to build Pakistan’s first Organ Sharing Network. Dr. Effendi also believes in writing for change. He tweets as @Jahanzebeffendi (twitter.com/Jahanzebeffendi) and can be contacted at firstname.lastname@example.org