KARACHI, Dec 27: While the city is no stranger to acts of violence and terrorism, it has emerged that though Karachi’s hospitals may well be able to deal with an emergency if they work together, a lack of coordination and paramedic training may cause an increase in the number of casualties.

When casualties from the siege in Mumbai on Nov 26 began to arrive at area hospitals, there was a sense of shock at the sheer scale of the attacks. Nonetheless, Mumbai was equipped with a centralised emergency response plan, with the municipal authorities coordinating action in the control rooms of the fire department, police and hospitals. While criticism has been levelled at the speed and efficiency of the response, doctors and personnel working within the system say that it was an asset to have a centralised authority with whom they could remain constantly updated.

So the question arises: just how prepared is Karachi, Pakistan’s biggest city, for an attack on the scale of the one in Mumbai, in terms of its police, fire department and medical emergency response?

‘Pre-hospital care needed’

The first response to a medical emergency is usually from private ambulance providers. Faisal Edhi, of the Edhi Foundation (which operates 300 ambulances in the city), says that an ambulance will usually arrive on the site of a disaster within two-five minutes of the call to the Edhi control room.

“The facilities in our ambulances, however, are not very good,” he admits. “There are two types of medical response to emergencies: pre-hospital and hospital care. We cannot provide pre-hospital care because most of our staff is not trained in that, and neither do we have the equipment.” Edhi ambulances will only transport casualties to the hospital from the site of disasters. Mr Edhi explains that 40 members of the Edhi staff did receive paramedic training at Civil Hospital several years ago, but the foundation has not been able to repeat the exercise.

“The lack of pre-medical care,” says Dr Saeed Quraishy, Medical Superintendent at Civil Hospital Karachi, “definitely increases the number of casualties [in disaster situations].”

But the lack of pre-medical care is not the only issue for the ambulance services. A lack of coordination, particularly at the site of large-scale disasters, means that the ambulances often line up and pick up bodies before the wounded, and then transport almost all the casualties to the same hospital. “The ambulances just get to the site and shift the wounded to the nearest hospital,” says Dr Quraishy. “There needs to be more coordination, a unified system, so that the casualties are shared between the different hospitals: Civil, the Jinnah Postgraduate Medical Centre, Abbasi Shaheed Hospital and Liaquat National Hospital.”

Dr Seemin Jamali, head of the accident and emergency department at the JPMC, agrees: “Casualties will rise because of a lack of coordination and management issues. Ambulances should be directed to different hospitals, so that no one is overloaded.” Dr Jamali speaks from experience: when the late Benazir Bhutto’s convoy was attacked on Oct 18, 2007, all of the over 200 casualties were taken to JPMC, and almost none to Civil Hospital.

‘CHK response plan being updated’

Once the casualties arrive at the hospitals, the emergency departments take over. CHK has an emergency department with two emergency operating theatres, and supplies for 200 patients immediately on hand. Medical supplies for a further 1,000 are available in a locked store, while other operating theatres are vacated and used in emergencies.

The hospital lacks a formal emergency response plan, as the existing plan is “out of date and is being updated,” according to Dr Shakeel Malik, the Assistant Medical Superintendent. The hospital is thus in the process of formalising its emergency response procedures, though at present doctors at the hospital say there is an informal system in place which works. Hospital staff is trained in emergency care techniques.

But while officials at the hospital say CHK can handle an emergency where there are 200 wounded, well placed sources put that number closer to 50 or 60. “The casualty department is a mess, and the emergency department will not be able to handle that many casualties all together,” said a senior doctor at the hospital, speaking on condition of anonymity. The doctor also pointed out that road access to the emergency department is often blocked by traffic or roadside vendors.

One of the failings of the system, admits Dr Quraishy, is the lack of coordination. “We have no coordination with the ambulance services and some coordination with the police and Rangers. This is the major flaw in the system – we do not have any coordination even with JPMC,” he says.

A source at the hospital also stated that while the Sindh government has apparently devised a plan for emergencies, it has never been made available to Civil Hospital or implemented in practice.

Over at JPMC, the situation is slightly different. Dr Seemin Jamali has prepared a set of emergency response procedures, which are updated every month and re-evaluated periodically. After each disaster, a debriefing is held to discuss what the staff did well, and what they can improve on. JPMC’s accident and emergency department handles 650-750 cases on a regular day, and Dr Jamali says it can handle up to 150 patients simultaneously in case of a disaster. The emergency department is stocked with supplies for 500 patients at any given time, and has 18 operation theatres. Staff at the hospital is trained in emergency care, and basic trauma care courses occur periodically.

‘There is no backup for us’

The two hospitals do share a common concern, however: security. Officials at both hospitals said that at times of major emergencies they require security personnel to be able to cordon off areas, manage traffic (both human and vehicular) and secure the area. “When a mob forms, we have no means of controlling it,” says Dr Quraishy, “and that harms our efforts.”

Dr Jamali told Dawn that on Jan 28, 2008, a grenade was found on the person of a wounded man brought to the emergency department after a police encounter. “There is no backup for us, no security,” she said. “What if that grenade had exploded in the emergency department?” she asked, showing this reporter a picture of the grenade in question, lying on an operating table.

Looking forward, the Civil Hospital is aiming to begin work on a new accident and emergency ward and is currently working on improving patient flows into and out of the emergency department, as well as building stretcher bays.

Karachi’s city district government, meanwhile, has purchased a fleet of nine fully equipped ambulances, which it will put into service during the first week of January 2009. The ambulances, according to EDO Health Dr A.D. Sajnani, will have trained paramedics on hand, and will initially be deployed from Civic Centre.

The next part of the series will deal with the nature of the security forces and the fire department’s response to a major terrorist strike in Karachi.