Ideating Role of Hospitals in a Civil Disturbance: A Multi-pronged Strategy

On the 25^th of August 2017, Chandigarh, a famous city in the northern part of India was thrust into national spotlight. Since 23^rd August 2017, parts of two states in northern India — Haryana, Punjab, and Chandigarh had been under a security lockdown as a large number of (reportedly 200, 000) supporters of a sect leader amassed Panchkula district [1], ahead of a court verdict after the conviction of a sect leader. His followers turned violent, and poured into the streets of the neighboring city of Panchkula. Threats were ongoing against city’s property and police, and uncertainty remained as what would happen next. A heavy contingent of security forces was deployed and another ten companies were kept on standby [2]. The crisis deepened and manifested into a violent public disturbance and civil disorder, wherein 30 people were killed and almost 300 people were injured [3].

In the current times, incidents that provoke civil unrest are becoming more widespread. Such incidents are posing new challenges to the local health system in the affected geographical area. The literature reviewed reveals few articles on this important aspect worldwide, wherein mainly medical management and future planning [4], the role of nurses [5], and the role of hospitals [6] has been described in civil unrests. This narrative will define civil unrest and enlist issues that should be considered in civil unrest emergency response preparedness plans by the hospitals.

Our hospital is a 1948 bed tertiary care university hospital having a level 1 Advanced Trauma Centre very well equipped with an Intensive Care Unit (ICU), Operation Rooms and highly trained multiskilled Faculty, Residents, Nurse and other paramedical staff trained in trauma care.

Therefore, it was evident that our hospital would need to provide coordinated, continuous support to ensure the availability of essential health services, medications, and supplies for the patients arriving at our center.

Case Report

Following the conviction of the sect leader, alleged supporters went on a rampage setting fire to vehicles, government buildings, petrol stations, media vans, and railway stations. In response, the civil administration ordered the security forces to intervene, and the police and paramilitary forces fired on charged mob [3]. As a result, on 25th August 2017 at around 6.00 PM, causalities started trickling into our trauma center in ambulances. In all, we at our trauma center received 67 patients.

Discussion

Disaster management requires optimal planning that begins with a comprehensive risk assessment and vulnerability analysis, to identify the most likely threats to a particular hospital and community. However, as civil unrest situations are somewhat unique, hospitals might require special focus and a distinctive plan. Our plan was what we called the “contingency plan” in the hospital; an emergency scenario with an acute situation requiring an immediate and coordinated response. As a leading hospital which is equipped with both broad- and super-specialties, we immediately swung into action and the contingency plan was activated in no time. The plan ran like a code, with a centralized leadership, and closed-loop communication. However, management of the unrest was unpredictable and unnerving on how to adequately respond to such a situation and uncertainty abounded that what will happen next. This uncertainty resulted in unforeseen challenges that were not deliberated in usual challenges of disaster management. The hospital had not experienced such a situation in the past and learned new lessons that we are highlighting here:

1. Arranging consumables: The storekeepers dealing with surgical items, linen items, and general items were asked to stay back at the hospital to provide inventory for the incoming patients. Even though live-saving consumables are available for all patients all time, yet costly consumables such as orthopedic implants are not available, patients have to arrange these from out of pocket. The hospital’s pharmacy runs around the clock, so it functioned as usual. However, the local market had closed down. In our hospital, a significant out of pocket expenditure is incurred by the patients as all the items required for treatment are not provided by the hospital. Since the patients (during the civil unrest) were not accompanied by their attendants, the hospital had to purchase items. This posed a challenge since the local market had closed down. Known vendors were thus contacted and asked to defer their closure as long as possible and the probable requisite items were sourced in advance, as well as during the inflow of patients. This was possible only because of a good store-vendor relationship.
2. Availability of staff for the next day: Most of our staff lived in the neighborhood affected by the riots and were equally affected by the situation prevalent in the city. A large number of employees coming to the hospital from adjoining areas (including the authors) faced a lot of difficulty in reaching the workplace as the borders were sealed and traffic movement was discouraged. We had to balance this dedication and desire to remain functional with a potential safety threat to our staff.
3. Arranging food items: The Dietetics department was asked to prepare sandwiches and working dinner for the staff who were asked to stay back. However, the food proved inadequate since a large number of doctors and nurses stayed back. It was then decided that the shops selling food items in the premises be asked to provide available snacks or other eatables at credit to the doctors/nurses/other staff which was reimbursed by the hospital later on the production of bills.
4. Patient tracking: The staff at the hospital reception counter prepared a separate list of patients from the site of unrest to distinguish them from other patients. This was necessary to provide ready information to the law enforcement authorities to take requisite legal action as per the law.
5. Redundancy or availability of beds: As per routine disaster plans, additional space may be created by discharging patients due for elective procedures, however, it may not be feasible or ethical in case of a civil unrest. The epicenter of the violent protests was put under curfew — how would anybody travel to such place if required? Will it be ethical to discharge vulnerable group of patients such as females and children in the evening or at night hours, or even otherwise?
6. What is successful management of a civil unrest: The most important question that begs attention is — how do we define successful management of a disaster from a hospital’s perspective? What should be stated as an outcome? Imagine a scenario where all the patients who reported to our emergency, died. Would it still be called as successful management, considering the fact that we were able to initiate treatment of all the patients? Should merely being able to receive all the patients be the yardstick or something else?

Conclusion

Though relatively rare in comparison to other disasters, a civil unrest is something hospital administrators should have on their radar. Some events are unique to civil disturbance and specific countermeasures need to be taken to mitigate them. Will there be another such event? We don’t know, and certainly pray not. However, we are confident that our team will be able to respond to such an event with better planning, dexterity, and compassion.

A limitation of this case report is that the sequence of events that occurred was not documented resolutely; as a result, it may contain certain omissions or chronological differences for some events. Future studies may focus on a methodical collection of information that will help policy makers to develop adequate hospital response/strategies.

References

1. Rahim conviction leads to violence; 30 killed; Dera chief jailed in Rohtak. Hindustan Times [Internet]. [cited 2018 July 8]. Available from: https://www.hindustantimes.com/punjab/gurmeet-ram-rahim-rape-verdict-live-dera-sacha-sauda-chief-to-appear-in-panchkula-court-punjab-haryana-on-high-alert/story-YO4q3FLriRRV8zpaL0ZfAO.html
2. Heavy police force deployed at Dera branches in Doaba, Guru Gobind Singh Stadium converted into temporary jail. The i8ndian express [Internet] [cited 2018 July 9]. Available from: https://indianexpress.com/article/india/gurmeet-ram-rahim-singh-rape-conviction-heavy-police-deployment-dera-branches-doaba-4813362/
3. Gurmeet Ram Rahim held guilty of rape, supporters run riot, 30 killed in Haryana violence | India-news | Hindustan Times [Internet]. [cited 2018 Jan 7]. Available from: http://www.hindustantimes.com/india-news/godman-gurmeet-ram-rahim-held-guilty-of-rape-dera-supporters-run-riot-30-killed-and-200-injured-in-violence-in-haryana/story-BWjkryRVb9191VJ9LUbJ5J.html
4. Ballantyne B. Medical management of the traumatic consequences of civil unrest incidents: causation, clinical approaches, needs and advanced planning criteria. Toxicol Rev 2006; 25:155–97. [doi:10.2165/00139709-200625030-00003]
5. Lavin R, Goodwin Veenema T, Calvert WJ, Grigsby SR, Cobbina J. Nurse Leaders’ Response to Civil Unrest in the Urban Core. Nurs Adm Q 2017; 41:164–9. [doi:10.1097/naq.0000000000000223]
6. Hospital’s Role in Civil Riot. N Engl J Med 1968; 278:51–2. [doi:10.1056/nejm196801042780126]