aPOCT•CTR, Pathology and Laboratory Medicine, School of Medicine, University of California, Davis, USA, and Affiliate Faculty, Chulalongkorn University
bLogistics Management-Transportation Institute and cCollege of Population Studies, ChulalongkornUniversity
Point-of-care testing (POCT)1 provides diagnostic test results quickly where they are needed the most, that is, at or near the site of patient care. Our research goals include integrating POCT with health care delivery in order to cost-effectively improve patient outcomes in Thailand. For example, when patients experience chest pain, POC blood tests for myocardial injury markers, cardiac troponin I or T, performed qualitatively (yes/no result) at community hospitals and quantitatively at regional hospitals provide immediate diagnostic evidence of heart muscle damage that helps speed triage and trigger life-saving treatment.2 That strategy for integrated regional care in Sakaeo and Isaarn provinces represents one recommendation we presented in the August 2004 Fulbright Newsletter (vol. 10, pp. 7-8).
We also recommended that for community hospitals, the MOPH provide whole-blood analyzers that quickly perform key tests, such as simultaneous blood gases [pO2 and pCO2], pH, potassium, ionized calcium, glucose, and hemoglobin/hematocrit in 1-2 minutes. More broadly, we recommended that future health care in Thailand integrate care paths with on-site diagnosis, emergency support, and critical care testing for acute care, intensive care units (ICUs), and operating rooms (ORs). Additionally, patients should receive devices for self-monitoring, such as blood glucose meters, a type of POCT that the diabetic patient can use in the home and elsewhere to guide therapy, control blood glucose, and prevent complications.
In this issue, we report on areas affected by the tsunami and its impact on local health care facilities that we visited while conducting field research in Phuket, Phang Nga, Krabi, and Trang provinces during April, 2005. We also surveyed the Surin and PhiPhiIslands. Another Sumatra-Andaman earthquake and tsunami may occur because of increased co-seismic stress and triggered earthquakes on the contiguous Sunda trench subduction zone and neighboring vertical strike-slip Sumatra fault.3 Continued high risk warrants advanced preparedness, warning systems, and improved emergency responsiveness.
In tsunami-affected areas, care of the most serious acute injuries, such as aspiration from drowning or near-drowning, trauma, and lacerations with blood loss, would have benefited from POCT in emergency rooms, critical care testing in ORs and ICUs, and improved disaster preparedness. During the two weeks following the tsunami, 398 patients were in intensive care, 1,254 underwent major surgical procedures, and 80,000 received other types of care from mobile teams.4 The Thai Society of Critical Care Medicine currently is discussing disaster response and in December, plans to hold focus sessions at a national meeting in Bangkok, where one of us (GJK) will present POCT strategies.
The tsunami affected all levels of health care. In some sites, such as KamalaBeach, Phuket province, the local PCU (primary care unit), situated slightly above the elevation of the nearby beach (Figure 1), was incapacitated when the water hit a high level of 10.05 meters. During the tsunami (Figure 2), staff escaped to the second (main) floor of the structure, which, they reported, shook under the stress of the torrent of water, but fortunately, was not overturned or uprooted from its foundation like so many of the smaller concrete structures that we saw at ruined resorts in the area and farther north along the Phang Nga coastline. Care of patients at KamalaBeach shifted temporarily from the PCU, which was closed, to a rescue center in Kamala village about 1 km inland. Medical problems included acute injuries, respiratory complications, infectious diseases, and psychological stress, which lingers and now is considered one of the main challenges for patient management.
The southwest coast of Phang Nga province suffered some of the worst damage from the tsunami. The resort areas of Khao Lak and the village of Baan Naam Khem were devastated. While Takuapa Hospital, the local regional 177-bed general hospital, lacked an anesthesiologist, intensivist, and cardiologist, rehearsal of a “major incident policy” two weeks before the tsunami helped minimize inpatient deaths in the face of 986 victims presenting to the emergency room on 26 December 2004 (the day the tsunami hit) and 628 admissions. During the first week, there were 2,285 trauma patients seen, 683 operations, and frequent cases of aspiration assessed in severity by POC pulse oximetry, which measures oxygen saturation continuously in the blood.5 When the Takuapa Hospital ICU was filled to twice its normal capacity of six, patients were transferred to other hospitals, but the nearest major hospitals, Phuket and Surathani, are two hours away. The number of deaths that occurred during patient transfer is not known.5
Fortunately, the TakuapaHospital diagnostic laboratory had a whole-blood analyzer for critical care testing, although POCT in the hospital was limited to glucose meters, and the hospital still lacks quantitative testing for cardiac biomarkers. Hospital staff deaths related to the tsunami included a physician, nurse, and library assistant. One ambulance was lost. Care of the most frequent routine diagnoses (respiratory disease, diarrhea, hypertension, diabetes, chest pain, and motor vehicle accidents) was severely interrupted. Generally in Thailand, during the first two weeks, the incidence of acute diarrhea, respiratory problems, febrile illness, and wound infection increased.4 By the end of March 2005, 1,800 of 5,395 confirmed dead were identified, about 50% of whom were not Thai.6
PhiPhiIslands losses were sudden and substantial. Eye witnesses estimated the height of the tsunami at 10-15 meters. One young man we interviewed escaped narrowly by heading his small boat into the tsunami as it approached shore. With three tourist passengers on board, the boat barely topped the crest. Then, quickly bailing water, they avoided sinking. All on board survived, but village colleagues on shore were not so lucky. Locals stated that 1,000 died with many bodies yet to be found. Devastation of families, housing, infrastructure, jobs, and the tourist industry caused a striking decrease in the population on the Islands.
Before the tsunami as many as one hundred patients per day visited the PhiPhiIslands clinic. Medical problems included diarrhea, sunburn, respiratory illness, marine injuries, and occasionally, chest pain. Diagnostic testing was limited to glucose meters, spun hematocrit, and urine dipsticks for protein and glucose. Treatment was limited as well. The only doctor on the Islands, a young man who recently completed training, survived the tsunami by climbing onto the roof of the hospital, which was under construction, then out onto a branch of a tree. However, a pharmacist attending to patients was found dead on the beach. Recovery has been delayed because workers will not return to the Islands. Now, medical care is scant. Nurses from Krabi province rotate to provide daytime clinic service. Completion of the hospital has been stalled. Heroically, the doctor remains in service dedicated to his patients.
Figure 3 shows the PhiPhiHospital site under construction during an earlier survey (by GJK) in December 2003. The photo was taken from a pedestrian pathway several meters away from and north of the beach. At the time, the small clinic (back right at the end of the walkway) provided rudimentary health services. Figure 4 shows that the partially completed hospital shell now stands uncomfortably close to the water’s edge. A ten-bed ICU was planned for the corner room with large windows in the front of the building facing the signpost in the photo. The tsunami swept through the structure and destroyed equipment inside, but it also swept away uncountable thousands of cubic meters of sand, removed the walkway in front of the hospital, destroyed electrical service (not yet restored), disrupted drainage systems, and narrowed the sand isthmus on which the structure stands, rendering it vulnerable to subsidence, tropical storm damage, and the next tsunami, if and when one hits.
Those we interviewed felt that the hospital should be relocated to a higher elevation in a safe site. After all, they said, the hospital represents one of the most critical facilities on the Islands and should not be the first disabled during a crisis. Relocation represents a tough decision for health planners in view of the prior investment, but a permanent and secure hospital on Phi Phi Islands is deemed essential, in our opinion, since the nearest emergency facilities are Krabi Hospital (42 km) and Vachira Phuket Hospital (35 km), both accessible only by boat (about 2 hours including land transfers) or helicopter. However, the hospital boat was damaged by the tsunami and cannot be used now.
In an historic event where the death toll is approaching 200,000 from a tsunami that lasted only a couple of hours, lessons can be learned from the Moken people (“sea gypsies”) whom we visited on the Surin Islands. The villager elder we interviewed described how Mokens “read the sea” based on the “story of the wave” told since “old times.” Finally heeding his warnings of imminent death, all villagers escaped to higher elevation with no loss of life—unique among the multitude of cultures touched by the tsunami.
Based on our field research and with respect for the ancient power of the sea, we offer the following strategic recommendations—
• Special Sites: PhiPhiIslands
Relocate the PhiPhiIslandsHospital away from the beach. Place it at an adequately high elevation to escape flooding and damage in the event of another tsunami. Install a helipad nearby for rescue transport. Staff the hospital adequately. Provide secure housing for staff above the danger zone. Equip and staff a diagnostic laboratory capable of whole-blood analysis and critical care testing. Set up an ICU. Implement portable and handheld POCT for emergency support in the event of electrical power failure. Carefully plan the PhiPhiIslands health care delivery solution so that it can serve as a model for other Thai island communities.
• Coastal Areas: Phang Nga and Phuket
Relocate PCUs away from beach areas. Develop and fully rehearse disaster plans, as was done at Takuapua Hospital5 before the tsunami. Upgrade essential emergency services, ICU bed capacity, physician specialists (e.g., anesthesia, infectious diseases, and cardiology), critical care testing, and POCT, including, for example, cardiac biomarker testing at regional and community hospitals.
• Critical Care: Mobile Response
Prepare mobile ICU and surgical facilities that will meet needs flexibly. Organize responding physician and nurse rapid response teams. Equip the teams with handheld and portable POCT, including whole-blood analyzers that perform blood gas, pH, electrolyte, and hematocrit/hemoglobin testing. Integrate disaster resources within and between provinces and islands. Initiate telemedicine and helicopter rescue services with integrated telecommunications.7
• Strategic Plan: Health Care Optimization
Building on our twenty-five policy recommendations for Sakaeo and Isaarn provinces,8 we recommend improved matching of: a) where patients are located (demography), b) where they receive immediate diagnosis and medicaltreatment, and c) integrated rescue and disaster preparedness, including substantially augmented use of critical care and POC testing for immediate evidence-based9 medical diagnosis, triage, and treatment.
1. Kost GJ, Ed. Principles and Practice of Point-of-Care Testing.Philadelphia: Lippincott Williams & Wilkins, 2002, 654 pages.
2. Kost GJ, Tran NK. Point-of-care testing and cardiac biomarkers: The standard of care and vision for chest pain centers. Cardiology Clinics 2005, in press.
3. McCloskey J, Nalbant SS, Steacy S. Indonesian earthquake: earthquake risk from co-seismic stress. Nature 2005 Mar 17;434(7031):291.
4. Centers for Disease Control and Prevention (CDC). Rapid health response, assessment, and surveillance after a tsunami—Thailand, 2005-2005. MMWR Morb Mortal Wkly Rep 2005 Jan 28;54(3):61-64.
5. Wattanawaitunechai C, Peacock SJ, Jitpratoom P. Tsunami in Thailand—disaster management in a district hospital. N Engl J Med 2005 March 10;352(10):962-964.
6. CDC. Health concerns associated with disaster victim identification after a tsunami—Thailand, December 26, 2004-March 31, 2005. MMWR Morb Mortal Wkly Rep 2005 Apr 15;54(14):349-352.
7. Garshnek V, Burkle FM. Applications of telemedicine and telecommunications to disaster medicine: Historical and future perspectives. J Am Med Inform Assoc 1999;-37.
8. Kost GJ, Peungposop N, Kulrattanamaneeporn C, Wongboonsin K, Charuruks N, Surasiengsunk S, Tran NK, and Surachaichan C. Minimizing health problems to optimize the demographic dividend: The role of point-of-care testing. In: Wongboonsin K and Guest P, Eds., The Demographic Dividend: Policy Options for Asia. Bangkok: College of Population Studies, ChulalongkornUniversity; Asian Development Research Forum; and the Thailand Research Fund, 2005, chapter 3, pages 56-89.
9. Daly J. Evidence-Based Medicine and the Search for a Science of Clinical Care.Berkeley, California: University of California Press, 2005, 289 pages.
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