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CM13.1-5 | Disaster Management — PBL Case

CLINICAL SETTING

It is 06:20 on a monsoon Tuesday in Tehri district, Uttarakhand. Overnight rainfall has caused the Bhilangana river to breach its embankment. By sunrise, water is entering three village clusters — Simlasa, Kharaun, and Dobra — with combined population ~6,800. You are Dr. Ananya Sharma, the lone medical officer at Kharaun PHC. Your phone rings: the block health supervisor is calling. 'Doctor, the ASHA workers are reporting bodies in the water and people on rooftops. The state highway is cut. PHC is still dry but the water is rising 2 feet an hour.' A tractor arrives at your gate with 19 people — some clearly in distress, some walking, one completely unresponsive.

Trigger 1: Nineteen at the Gate

The 19 arrivals are unloaded outside the PHC. You have one staff nurse, one MPHW, and a driver. Your emergency kit contains: oral rehydration salts, basic wound care supplies, a manual BP instrument, a pulse oximeter, and paracetamol. You have no IV fluids or oxygen. Your mobile phone has one bar of signal. The 19 include: (A) a 68-year-old man — unresponsive, cold, breathing at 36/min, no radial pulse; (B) a 45-year-old woman — breathing at 24/min, radial pulse present, very confused; (C) five adults with cuts, bruises, and shivering but walking and speaking coherently; (D) a mother holding a toddler who has not cried since rescue; (E) eleven adults with various minor complaints (headache, diarrhoea, anxiety). More people are expected to arrive within 30 minutes.

DISCUSSION POINTS

  • Apply the START triage system to groups A, B, C, D, and E. What is the triage colour for each group, and which is the single highest-priority casualty?
  • With limited supplies and staff, what are your first three actions in the next 10 minutes? Prioritise and justify.
  • What information do you need from the block health supervisor to plan for the incoming surge? List four specific data points.
Click to reveal Trigger 2: Two Hours Later — The Situation Expands (discuss previous trigger first!)

Trigger 2: Two Hours Later — The Situation Expands

Two hours have passed. Casualty A died before you could intervene. The toddler (D) is now breathing and has been stabilised with glucose water. An NDRF team arrives and informs you that a total of 340 people from the three villages will need medical evaluation over the next 6 hours. A local government school 500 metres from the PHC has been designated as the District Disaster Medical Camp by the DDMA. The District Medical Officer has called to say a mobile medical unit with IV fluids, oxygen cylinders, and a surgeon is en route — ETA 3 hours. He asks you to 'manage the camp until it arrives.' An ASHA from Simlasa village reports that two people there have had vomiting and diarrhoea since yesterday, before the flood — she suspects it may be something in the water.

DISCUSSION POINTS

  • How would you set up the school as a temporary medical camp? What are the three functional zones you would establish, and what goes in each?
  • The ASHA's report raises concern about a possible waterborne disease outbreak. How do you distinguish between flood-related acute gastroenteritis and a pre-existing outbreak? What immediate public health action would you take?
  • What does your role coordination with the DDMA look like at this point? Who is the Chairperson of the DDMA, and what specific requests do you make through official channels?
Click to reveal Trigger 3: Six Hours In — The Wave After the Wave (discuss previous trigger first!)

Trigger 3: Six Hours In — The Wave After the Wave

The mobile medical unit has arrived and the camp is functioning. 287 of 340 people have been assessed. Four deaths have occurred (all elderly, two from drowning, two from hypothermia). The surgeon has evacuated two critical cases to district hospital by NDRF vehicle. It is now 12:30. The DDMA Chairperson calls you directly: 'Doctor, the media is outside. The district collector's office wants to know if this disaster could have been prevented. Also, the block development officer is asking whether we should start distributing water purification tablets to the villages. And I need your estimate — how many people will need medical follow-up in the next 4 weeks?' You have 20 minutes before the press briefing.

DISCUSSION POINTS

  • The flood embankments in Tehri district had been flagged as inadequate in the 2019 state disaster preparedness audit. What mitigation activities, if implemented after that audit, might have reduced today's casualties? Distinguish between structural and non-structural mitigation.
  • Should water purification tablets be distributed now? Justify your answer with reference to the post-disaster disease surveillance priorities for flood-affected communities.
  • Prepare a 60-second oral briefing for the District Collector that answers all three of his questions. Your briefing must be factually accurate, reassuring without being dismissive, and must recommend at least one immediate action.

Group Task Assignments

Group 1: START Triage and Mass Casualty Prioritisation

  • Map all five casualty groups (A-E) through the START algorithm with explicit step-by-step justification for each
  • Identify the most common triage error in flood mass casualty incidents (undertriage vs overtriage) and propose one quality check that could be performed in a field setting

Competencies: CM13.3, CM13.5

Group 2: NDMA Institutional Framework

  • Draw the three-tier disaster management structure under DM Act 2005, naming the Chairpersons at each level
  • Identify the statutory funds available under the DM Act 2005 (NDRF/SDRF) and trace the sequence of fund activation for a district-level response

Competencies: CM13.4

Group 3: Disaster Cycle and Post-Disaster Surveillance

  • Place each event in this case (flood embankment failure, NDRF deployment, medical camp setup, water tablet distribution) on the disaster management cycle and justify the phase
  • Propose a 4-week post-flood disease surveillance protocol specifying the diseases to monitor, the data sources, and the reporting chain

Competencies: CM13.2

Group 4: Decontamination and CBRN Comparisons

  • Compare the decontamination requirements for a chemical (CBRN-C) incident vs a flood (natural disaster): what is different and what is the same in terms of Hot-Warm-Cold zone organisation?
  • Identify what additional equipment and protocols the PHC would need if the flood had breached a chemical storage facility upstream (combined natural-technological disaster)

Competencies: CM13.3

Group 5: Mitigation, Prevention, and the PHC Physician's Role

  • Review the Odisha 1999 vs 2013 cyclone comparison and identify the three preparedness activities most responsible for the mortality reduction. Evaluate which of these three activities could be replicated for flood-prone Uttarakhand
  • Draft a 200-word PHC Disaster Preparedness Checklist that a PHC medical officer should complete BEFORE a disaster, based on the lesson of Trigger 1 resource limitations

Competencies: CM13.2, CM13.5

Learning Issues

Research these questions and bring your findings to the discussion.

  1. [CM13.1] Define disaster using the UN/WHO definition and classify today's flood event. How does 'exceeding coping capacity' manifest in the scenario?
  2. [CM13.2] Map all activities described across the case onto the correct phase of the disaster management cycle. What phase does the water tablet decision fall under, and why?
  3. [CM13.3] Describe the START triage algorithm in full detail. Identify which of the five casualty groups in Trigger 1 represents the most dangerous undertriage error if misclassified.
  4. [CM13.4] Describe the complete three-tier institutional structure under the DM Act 2005, naming Chairpersons at each level. What are the four statutory funds/forces created by the Act?
  5. [CM13.5] In this simulated environment, what are the three most important decisions Dr. Sharma made correctly, and what is the one thing she could have done differently to improve outcomes?