Lessons learned from a landslide catastrophe in Rio de Janeiro, Brazil

Abstract

On January, 2011, a devastating tropical storm hit the mountain area of Rio de Janeiro State in Brazil, resulting in flooding and mudslides and leaving 30,000 individuals displaced.
This article explores key lessons learned from this major mass casualty event, highlighting prehospital and hospital organization for receiving multiple victims in a short period of time, which may be applicable in similar future events worldwide.
A retrospective review of local hospital medical/fire department records and data from the Health and Security Department of the State were analyzed. Medical examiner archives were analyzed to determine the causes of death.
The most common injuries were to the extremities, the majority requiring only wound cleaning, debridement, and suture. Orthopedic surgeries were the most common operative procedures. In the first 3 days, 191 victims underwent triage at the hospital with 50 requiring admission to the hospital. Two hundred fifty patients were triaged at the hospital by the end of the fifth day. The mortis cause for the majority of deaths was asphyxia, either by drowning or mud burial.
Natural disasters are able to generate a large number of victims and overwhelm the main channels of relief available. Main lessons learned are as follows: 1) prevention and training are key points, 2) key measures by the authorities should be taken as early as possible, and 3) the centralization of the deceased in one location demonstrated greater effectiveness identifying victims and releasing the bodies back to families.

Full text

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Introduction: On January, 2011, a devastating
tropical storm hit the mountain area of Rio de Janeiro
State in Brazil, resulting in flooding and mudslides
and leaving 30,000 individuals displaced.
Objective: This article explores key lessons learned
from this major mass casualty event, highlighting pre-
hospital and hospital organization for receiving multi-
ple victims in a short period of time, which may be
applicable in similar future events worldwide.
Methods: A retrospective review of local hospital
medical/fire department records and data from the
Health and Security Department of the State were ana-
lyzed. Medical examiner archives were analyzed to
determine the causes of death.
Results: The most common injuries were to the
extremities, the majority requiring only wound cleaning,
debridement, and suture. Orthopedic surgeries were the
most common operative procedures. In the first 3 days,
191 victims underwent triage at the hospital with 50
requiring admission to the hospital. Two hundred fifty
patients were triaged at the hospital by the end of the
fifth day.The mortis cause for the majority of deaths was
asphyxia, either by drowning or mud burial.
Conclusion: Natural disasters are able to generate
a large number of victims and overwhelm the main
channels of relief available. Main lessons learned are as
follows: 1) prevention and training are key points, 2) key
measures by the authorities should be taken as early as
possible, and 3) the centralization of the deceased in one
location demonstrated greater effectiveness identifying
victims and releasing the bodies back to families.
Key words: landslide, disaster medicine, mudslide
IInnttrroodduuccttiioonn
On the night of January 12, 2011, a devastating
tropical storm hit the mountain area of Rio de Janeiro
State in Brazil (~2,100 m above the sea level). Local
authorities recorded a volume of 180 mm of rainwater
in 30 hours (130 mm in 24 hours), resulting in flooding
and mudslides, more than 30,000 were persons dis-
placed, 700 were injured, and there were 845 immedi-
ate deaths. One year after the disaster, the number of
dead and missing persons was estimated to be 1,300.
In this particular natural disaster, sequential
land/mud avalanches struck different geographic
zones affecting more than 800,000 inhabitants (in
three cities, four strikes).The event overwhelmed local
emergency medical services, regional hospitals, and
fire and police stations.The result of mudslides and the
incredible volume of rainwater over a short time period
resulted in devastating floods that uprooted trees, tele-
phone and electric poles; damaged water and fuel lines;
and impassable roads and bridges which severely
needed recovery efforts. Communication was badly
affected because of the lack of electricity in the crashed
region as well as cell phones signals (Figures 1 and 2).
This article explores key lessons learned from this
major mass casualty event, highlighting the preparing
gaps for effective response in the following three major
areas: 1) emergency medical care delivery, 2) evacua-
tion and housing for displaced persons, and 3) man-
agement of mass fatalities.
MMeetthhooddss
A retrospective review of local hospital medical
records, fire department (FD) records, and data from
www.disastermedicinejournal.com 11
Lessons learned from a landslide catastrophe in Rio de Janeiro, Brazil
Bruno Monteiro Tavares Pereira, MD, MSc; Wellington Morales, MD; Ricardo Galesso Cardoso, MD;
Rossano Fiorelli, MD, PhD; Gustavo Pereira Fraga, MD, PhD; Susan M. Briggs, MD, MPH
ORIGINAL ARTICLE
DOI:10.5055/ajdm.2013.0000
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the Health and Security Department of the State were
analyzed. News media resources were also used to eval-
uate this mass casualty incident (MCI). Hospital
records and government data were used to provide
accurate information regarding hospital triage, types of
injury, need for surgery, patient transfers, and the
extent of hospitalization. Medical examiner archives
were analyzed to determine the causes of death. An
analysis was performed to determine where changes to
existing systems and protocol refinements were needed.
MMeeddiiccaall rreessppoonnssee ttoo tthhee ddiissaasstteerr
There were no official disaster plans for the region.
The majority of healthcare providers had little or no train-
ing in disaster management or MCI medical assistance.
American Journal of Disaster Medicine
, Vol. 8, No. 3, Summer 2013
22
Figure 1. Affected cities in the State of Rio de Janeiro.
City One: Petropolis; City Two: Teresopolis; City
Three: Nova Friburgo.
Figure 2. Mudslide strike and flood.
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Field triage was initially performed by volunteers (neigh-
bors, friends, and family), due to inaccessibility of affected
areas thereby including the ability of response personnel
to rapidly respond, two hospitals in all three affected
cities provided medical care for victims of the disaster.
The main one and closest to the disaster zone was a 137-
bed hospital with five operating rooms (Figure 1:
Teresopolis/city 2).This institution was able to continue
to function with power supplied by two diesel energy gen-
erators. The chief of the Emergency Room was trained in
MCIs and was on service the day of the event. Under his
command and before receiving any official warning about
the incident, but expecting the worst, the emergency
department team started to prepare for receiving multi-
ple victims and functioned as the hospital Incident
Command location, even though no plan was previously
set for that. The ER team allocated patients to other sec-
tors, defined an in-hospital triage zone, implemented an
improvised triage method (red/yellow/green), enforced
security, made cell phones contact with other regional
hospitals for receiving transferred patients (yellow), and
contacted blood banks. A nearby gymnasium was estab-
lished to shelter victims triaged as green. The initial
emergency team was composed of one surgeon, one anes-
thesiologist, two GYO, one pediatrician, one critical care
specialist, and three GP’s, plus the chief of the ER.
Around 6:00 AM, the first of many casualties
arrived at the hospital, including a 9-year-old boy.
Three of those were triaged as green, identified (not
included in hospital statistics) and dispatched to the
green zone (gymnasium). Three patients were classi-
fied as yellow and admitted. The last admitted patient
was classified as red and admitted to the intensive
care unit. Two of these victims required surgery
(orthopedics). Even though no official disaster plan
was set, the fact of one medical team member being
present at the hospital with disaster preparedness
proficiency helped in in-hospital mass casualty man-
agement and naturally became a local leader. After
power was reestablished, television began broadcast-
ing news about the incident and its magnitude and
severity. Hospital employees (administrative, health-
care providers including surgical specialists, and
cleaning personnel) voluntarily started arriving at
the hospital, reinforcing the multidisciplinary team
already in place. At 8:00 AM, an official report from the
FD came through a FD ambulance reporting the mag-
nitude of the disaster scenario and its severity.
Large numbers of victims were brought by commu-
nity volunteers’ in the back of trucks, immobilized using
doors as backboards, and carried in homemade stretch-
ers in some cases using mattresses, clothing, and pieces
of wood. Dead bodies found at the scene were brought to
the hospital by volunteers, triaged as black and for-
warded to a zone outside the hospital in the same vehi-
cle they arrived for identification and storage, as no
official transport for decedents was available by that
time. In the first 24 hours, 136 patients were triaged as
red or yellow. As many patients as possible were identi-
fied, including those not admitted (green).
Eleven patients needed surgery, nonurgent sur-
gery cases were transferred to other nearby institu-
tions on the second or third day. The most common
injuries were to the extremities, with the majority
requiring only irrigation, debridement, and suture.
These patients were discharged on the same day,
relieving ER congestion. Patients in need of surgery,
critical care or infirmary admission never returned to
the ER (one-way triage of patients).
FFeeddeerraall ggoovveerrnnmmeenntt aassssiissttaannccee
Military and government support started arriving
at the disaster zone at the end of the first day, as well
as tons of donations (clothes, food, and personal
hygiene supplies). Helicopters helping in rescues and
to transport supplies were sent to safe areas. The
Navy force and the Rio de Janeiro State Fire
Department built campaign hospitals (Figure 3), and
a field Incident Command was created by all rescue
forces involved. Water was suspended for 24 hours
until analysis of contamination was evaluated.
Stations for ambulatory medical assistance (vac-
cine and infectious disease control), psychological
assistance and office stations to provide new ID docu-
ments, government financial help, and home alloca-
tions were built.
HHoommeelleessss aallllooccaattiioonn
Displaced casualties from these three major
affected areas were dispatched to several gymnasiums
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for shelter. Security was reinforced in the gymnasium
perimeter and only authorized personnel were able to
enter the area. An area of a basketball court was used
as a rest area. No food was allowed in this area, in an
attempt to have optimal environmental control. The
bleachers were used as storage for food and clothes,
separated in predetermined sections. Men and women
used the gymnasium lockers for personnel hygiene.
Military personnel guaranteed organization, security,
food and water supply to each shelter.
On the third day, 4,000 homeless or displaced peo-
ple had already been registered at the gymnasiums.
Animals were gathered, identified when brought by
families and placed in veterinarian shelter.
MMaannaaggeemmeenntt ooff ddeecceeddeennttss
All decedent remains were allocated in the same
nonrefrigerated area. A medical examiner office from
the capital of the State offered support for identifica-
tion (photos, digitals, dental studies, and DNA sam-
ples) and forensic examination, respecting all legal
and customs issues. Bodies were separated by geo-
graphic origin as they were brought in by search and
rescue teams to later identification by families.
Nearby, a victim identification office was built, and a
list of identified bodies was posted.
Once recognition was established, authorities
were able to use morphological data and pictures
brought by victim’s families for body identification. If
the identification matched all the data, the body was
then shown for family recognition. All bodies were
placed in coffins provided by the municipality and
delivered to funeral homes when claimed by families.
As body management was centralized in one place, the
identification process was expedited. Local authorities
offered psychological and grief support. Judicial offi-
cials provided the necessary administrative docu-
ments (ie, death certificate).
The cause for the majority of deaths was asphyxia,
either by drowning (25 percent) or mud burial (75 per-
cent). Traumatic injuries were observed in one third of
the victims, but were not determined as the cause of
death in any cases.
American Journal of Disaster Medicine
, Vol. 8, No. 3, Summer 2013
44
Figure 3. Brazilian Navy campaign hospital units.
12 Lessons learned from this MCI & plan gaps
Community Volunteers are the first to respond at scene: they
can be useful in helping rescue teams in minor activities
Communication between all involved teams and defined
areas (such as incident command unit, rescue teams, hos-
pitals, medical examiner office, and shelters) is essential
A Command Incident algorithm must exist and be ready
in a MCI
Authorities must have a disaster plan and recognize risk
areas to avoid worse scenarios (key measures to keep life
sustainable)
Emergency hospitals must have their own disaster plans
with each involved person having functional duties as
defined by the incident Command System
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DDiissccuussssiioonn
This article demonstrates lessons learned from a
devastating natural disaster that involved three cities
and a population of 800,000 inhabitants in the State of
Rio de Janeiro, Brazil. This disaster resulted in a large
number of homeless and fatal/nonfatal victims. The
region affected by the storm was a poor region with few
resources. The trauma system is very nascent or nonex-
istent, and there was no local plan to respond to disas-
ters. Except for personnel of the Fire Department, few
individuals had any predisaster training or experience.
Accidents with multiple victims require continuous
training and exercises.1,2 All disasters have common
medical and public health concerns as well as unique
risks related to geographic, social, economic, or political
differences. The event described in this study occurred
around midnight, affecting entire families. Much of the
hillside that collapsed was illegally occupied and disor-
derly, without prior planning for water runoff, thereby
increasing the chances of a catastrophe. The immensity
of the problem prevented the immediate arrival of spe-
cialized forces, worsening the situation of the victims
involved. Disaster prevention plans, as well as disaster
response, should be a priority of the authorities to
reduce the incidents of fatal and nonfatal casualties.
Volunteers, who were involved in the disaster but
did not get injured, performed the initial rescue. The
presence of volunteers is acceptable and described in
the literature, but caution is needed.1,2 Volunteers are
not experts and often become victims due to lack of
knowledge of scene safety. The fact that they are not
trained and do not perform effective triage decreases
the effectiveness of the disaster response.
In this event, despite little experience with disas-
ter management and almost all rescue forces being
affected by the disaster, local authorities and hospital
reference relief organized themselves well and pre-
pared for the reception and processing of multiple vic-
tims. A triage unit at the hospital entrance can greatly
help in correcting over-triage, which often occurs in
the field by nontrained personnel.4,5 In less than 24
hours, several units of government rescue, civilians
and military, were ready to assist victims, electricity
was reestablished and the most common forms of com-
munication made available.
The first 24 hours were undoubtedly the biggest
challenge in this event in all instances. Military aid is
essential in this type of disaster, especially when the
common means of movement have collapsed, such as
highways, streets, and bridges. The use of rotary wing
aircraft becomes mandatory for effective resolution of
a natural event that assembles.6
The concern by the authorities such as shelter, food,
water and personal hygiene, infection control, psycholog-
ical support, and security are critical to maintaining
order and minimize the effects of the disaster.4,7-11 In this
event, in the mountainous region of the State of Rio de
Janeiro, shelters were identified and controlled access
imposed. All volunteers working on site, as well as disas-
ter victims present in the shelters, were properly identi-
fied. These measures were sufficient so that authorities
recorded no violent acts. The delegation of activities was
to help everyone present in shelters shift their focus from
the catastrophe to a motivational activity, which also
helps in the psychological recovery of victims.11,12
Care of the fatal victims involved, respecting all
faiths and beliefs, and the availability and quick access
to information about the deceased assisted in the under-
standing of the population and comprehension of the
steps necessary to identify all the bodies.The centraliza-
tion of bodies into a large shed and additional forensic
trained staff expedited the identification of the bodies.
The cross-match of pictures delivered by relatives, with
www.disastermedicinejournal.com 55
12 Lessons learned from this MCI & plan gaps
(continued)
A triage unit at the disaster referenced hospital helps in
correcting over-triage
Trained teams are the key point of successful disaster relief
Military forces are helpful in most rescue operations and
support logistics
Shelters must be fast provided and security reinforced
Allocating dead bodies in a single designated facility facil-
itates identification, and family body claims
Digital pictures of the bodies can help family identifica-
tion faster
After the first 24 hours, the number of nonfatal victims
decreases
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photographs of bodies taken by forensic technicians, was
an easy and inexpensive method to identify many of the
unidentified bodies, saving more complex processes such
as dental analyses and DNA for those really needed.11-15
Another useful method to help with the identification of
bodies was splitting them by geographical region where
they were found. In events with large amount of victims,
this simple measure accelerates the identification
process.
We observed that, in this natural cause catastro-
phe as in others, a great number of victims were dead
at the scene due to the devastating force of the floods
and mudslides. Also, after the first 24 hours, the num-
ber of nonfatal victims decreases and usually more
resources (human and material) are available. In this
MCI, local officials provided financial aid and housing,
as well as documentations necessary for each citizen
(identity, social insurance, and death certificates).
CCoonncclluussiioonn
Natural disasters are able to generate a large num-
ber of victims and overwhelm the main channels of relief
available. Prevention and training is a key point; how-
ever, in the absence of it, disaster recovery measures can
be taken. Even with little guidance and proper training,
institutions can become organized for receiving simulta-
neous, multiple victims. The presence of a leader can
motivate a multidisciplinary team and establish steps in
caring for victims. Triage in the emergency department
by experienced physicians is essential.
Key measures by the authorities should be taken as
early as possible, including reestablishment of basic
measures to maintain life (electricity, food, clean water,
sanitation, and shelter), adequate provision of traffic on
roads, medical care, psychological, forensic and admin-
istrative. The centralization of the deceased in one loca-
tion demonstrated greater effectiveness to identify
victims and to release the bodies back to families.
Bruno Monteiro Tavares Pereira, MD, MSc, Assistant Professor,
Division of Trauma Surgery, Department of Surgery, School of
Medicine, University of Campinas, SP, Brazil.
Wellington Morales, MD, Associate Professor, Department of
Surgery, Teresópolis School of Medicine, Rio de Janeiro, Brazil;
Chief, Clinics Hospital of Teresópolis Emergency Department,
Rio de Janeiro, Brazil; Surgical Activities Coordinator of the
Health and Security Rio de Janeiro’s State Department, RJ, Brazil.
Ricardo Galesso Cardoso, MD, G.R.A.U. Flight Doctor (HEMS), Fac-
ulty of the Division of Trauma Surgery, Department of Surgery,
School of Medicine, University of Campinas, SP, Brazil.
Rossano Fiorelli, MD, PhD, Faculty of the Department of Surgery,
School of Medicine, University of Rio de Janeiro, RJ, Brazil.
Gustavo Pereira Fraga, MD, PhD, Chief, Full Professor of Surgery,
Division of Trauma Surgery, Department of Surgery, School of
Medicine, University of Campinas, SP, Brazil.
Susan M. Briggs, MD, MPH, Associate Professor of Surgery, Mass-
achusetts General Hospital, Harvard Medical School, Boston,
Massachusetts.
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