(COL.

)
YOGESH
Indian PRABHAKAR,
J. Anaesth. 2002;
46 (5) :: GHAISAL
409-413 TRAIN ACCIDENT

409

GHAISAL TRAIN ACCIDENT

Col T. Prabhakar,VSM1 Col Yogesh Sharma,VSM2
SUMMARY
With the ever-increasing mechanization, vehicular accidents are steadily increasing in magnitude and frequency. Large sections of
the population use some form of mass transportation like trains, buses and airplanes etc. Any accident involving these means of mass
transportation could have disastrous consequences. In this presentation we would like to share our experience at 158 Base Hospital
regarding the management of victims of a train accident resulting from a head on collision between two fast moving passenger trains.
The sudden deluge of 149 casualties including 46 dead although stretched our medical resources but helped us in fine-tuning our
disaster management plans. Some unusual and interesting patterns of injury were encountered.

Keywords : Disaster management, Railway accident.

Introduction
Trauma, called the neglected child of modern
society is the principal cause of death and disability in the
first three decades of life.1 Although authentic data
regarding mortality and morbidity following trauma is
hard to get, trauma accounted for over 43 lakh victims
which included 7 lakh dead in India in 1994.2
The economic loss to the nation is staggering in
the form of loss of millions of work hours added to the
cost of treatment. Improvements in prehospital trauma
care, establishment of regional trauma care centers, use
of safety devices like seat belts, improved automobile
design and imposition of speed limits have reduced death/
disability rates but a lot still requires to be done. 158
Base Hospital was exposed to an influx of mass casualties
resulting from one such unfortunate train accident. An
effort has been made to outline the profile of injuries and
to share our experience in their management.
Materials and methods
In the early hours of 02 August 1999 the Delhi
bound Avadh Assam Mail collided head-on into the Gauhati
bound Brahmaputra Mail at GHAISAL (Fig 1,2,3). It
was one of the worst train accidents in the country, which
left more than 800 people injured and 256 dead. 103 of
the injured and 46 dead were received at 158 Base Hospital
on 02 and 03 August 99 within a period of about 36
hours. Although a few hours prior information about the
arrival of mass casualties was received the sudden influx
of such a large number of casualties pushed the entire
hospital services to perform beyond themselves in order
to manage this disaster.
1. MD., Senior Advisor
(Anaesthesiology), 158 Base, Hospital; C/O 99 APO
2. MS (Gen Surg), MS (Ortho),
Classified Specialist (Surgery & Ortho),
Command Hospital; Chandigarh

Figure : 1

Figure : 2

Figure : 3

410

All the patients had been given first aid at the site
of accident by the meager local medical resources. In
addition one surgical team of 158 Base Hospital went to
the accident site to organize the evacuation of casualties.
All the cases were received at a special reception center
for first aid and documentation. Each case was seen on arrival
by a surgeon and allotted priority in the usual manner
i.e., P-1 cases requiring immediate resuscitation and urgent
surgery (these included open intraarticular fractures) P-2
cases requiring possible resuscitation and early surgery
including dislocations and open fractures. P-3 for all other
cases. In addition special priorities were allotted for spinal
and eye injuries. Resuscitation was carried out along with
a quick primary survey and continued in the operation
theatre/acute wards as indicated. All cases with open
wounds were given tetanus prophylaxis and antibiotics.
Subsequently the injuries were regionalized. Life
and limb saving surgeries were carried out as per priority
already allotted. Later the complete nature of injuries
were determined and secondary procedures carried out.
Injuries requiring treatment at specialized centers were
identified and evacuated to appropriate centers.
Some of the patients arrived in a shocked state
because of multiple injuries, airway obstruction, massive
bleeding or other trauma requiring urgent resuscitation
and early surgery. Patients were provided uninterrupted
intensive therapy in severe trauma cases following
operations that have suffered critical hypotension or
hypoxia preoperatively or intraoperatively. There were
no delayed operations or premature interferences.
Diagnosis and treatment were occurring simultaneously.
Anaesthesia was administered and maintained
despite poor patient status and staffing, sometimes without
the benefit of supportive laboratory and previous medical
data. There were high incidence of critical events like
often lengthy operating procedures, multiple, serial or
simultaneous diagnostic or therapeutic procedures. Four
patients required ventilatory support and one of them
required ventilation for ten days. All the patients were
successfully weaned off the ventilator.
Results
A total of 149 cases were received in a period of
about 36 hours, these included 46 dead. Out of the injured
there were 99 males (96.1%) and 04 females (03.89%). Of
the 103 injured, 72 cases (70%) were Army personnel, 09
(08.7%) were from Assam Rifles, 06(05.8%) each from
Air force and CRPF. There were 07 civilians and three
cases from other paramilitary forces. All the injured were
traveling in the leading compartments of the two trains.
After triage the distribution of cases were as per Table-1.
A total of 17 units of blood transfusion were given. No
single case required more than 04 units of blood transfusion.
Regional distribution of cases is given in Table-2.

INDIAN JOURNAL OF ANAESTHESIA, OCTOBER 2002

Table 1 : (Triage)
PRIORITY

No of CASES

PERCENTAGE

12

11.66%

31

30.01%

55

53.59%

05

04.95%

Priority-1
Polytruma
Thoracic injuries
Open intra-articular fracture
Priority-2
Acute dislocations
Open fractures
Others
Priority-3
Special priority
Cervical spinal injury
Dorsolumbar injury

Table 2 : Regional distribution of injuries

S. No
1.

REGION

No of Cases

Multiple superficial injuries

68

2.

Lower limb injuries

33

3.

Upper limb injuries

17

4.

Thoracic injuries

14

5.

Dislocations

09

6.

Head, neck & spine injuries

08

7.

Polytrauma

05

8.

Major lacerations

04

A total of 149 active procedures were carried out

during the course of management of the accident victims.
The various interventions are listed in Table-3 (Surgical
procedures/interventions). There were 40 major injuries
to the lower limbs in 33 cases. These included 32 fractures,
07 dislocations and one case of anterior compartment
syndrome in the leg. Description of the lower limb injuries
has been given in Table-4 (lower limb injuries). Details
of upper limb injuries are given in Table-5.
Table 3 : Surgical interventions
S No.

SURGICAL INTERVENTION

No

1.

POP application

43

2.

Suturing of lacerations

38

3.

Closed reductions

20

4.

Wound debridements

17

5.

ORIF (Open reduction internal fixation)

15

6.

Skeletal tractions

10

7.

External fixators

08

8.

Exploratory laparotomies

03

9.

Amputations

02

10.

Ventilatory support

04

11.

Tracheostomy

01

(COL.) PRABHAKAR, YOGESH : GHAISAL TRAIN ACCIDENT

Table 4 : Lower limb injuries (40 injuries in 33 patients)

S No
1.

2.

3.

4.

TYPE OF INJURY

No

Open fractures
Fracture shaft femur
Fracture tibia fibula
Bimalleolar fractures

(02)
(07)
(01)

Closed fractures
Fracture shaft femur
Subtrochanteric fractures
Fracture tibia fibula
Fracture patella
Malleolar & small bone Fractures

(02)
(01)
(05)
(04)
(10)

Dislocations
Anterior dislocation hip
Posterior dislocation hip
Central fracture
Dislocation hip
Compartment syndrome

10(26)

22(55)

07
(01)
(03)

(17.5)

(03)
01(02.5)

Table-5 : Upper limb injuries (24 injuries in 17 patients)

S.No

TYPE OF INJURY

1.

Open fractures
Humerus
Clavicle
Radius & ulna

(04)
(01)
(01)

Closed fractures
Humerus
Clavicle
Radius & ulna
Olecranon

(03)
(03)
(04)
(02)

Dislocations
Shoulder
Elbow

(01)
(01)

2.

3.

4.

Crush injury/Compartment syndrome

Neuropraxia radial, ulnar
and median nerves
Crush injury requiring
amputation

No (%)
06(25)

12(50)

02(08.3)

04(16.7)
(03)
(01)

All the seven cases of open fractures of the tibia

including one case of double segmental tibial fracture
were managed with wound debridement and external
fixators to begin with. All 07 dislocations of the hip were
reduced under general anaesthesia and managed with
skeletal traction after ensuring concentric reduction. Most
of the displaced fractures were managed with open
reduction and internal fixation if closed treatment was not
satisfactory. Fractures of the humerus predominated in
the upper limb injuries. One case had bilateral open
fractures of the humerus with neurological complications
in the right side, however he recovered fully with

411

conservative management after repeated debridements.

There were three cases of closed crush injuries of upper
limbs without fractures. There were 2 cases of flail chest
among the patients with thoracic injuries, one of which
had to be managed on ventilator for 10 days. The 08
cases of head, neck and spinal injuries included 04 (50%)
skull fractures, 02 (25%) fractures of the cervical spine.
All these cases were managed conservatively.
Among the three cases of blunt abdominal trauma,
one had an isolated splenic injury requiring splenectomy,
the other had combined splenic and hepatic lacerations
and the third case had a large retroperitoneal haematoma
along with a mesenteric injury. All these cases required
resuscitation with IV fluids and blood before surgery.
Missed injuries
In this series there were 06 missed injuries (05.8%).
These included one case of fracture olecranon in a case
of splenic rupture. Three cases of fractures of the clavicle
were missed in cases of polytrauma, and malleolar fractures
were missed in 2 cases. All the missed injuries were
discovered after the patients returned for review after
visiting their homes with fresh complaints.
Outcome
Sixty-seven cases were discharged within 15 days
of admission. Six cases were discharged between 15
days and 2 months and 29 cases required hospitalization
beyond 2 months (these were cases of open/complicated
fractures). Two cases of traumatic paraplegia were transferred
to spinal cord injury centers and 2 cases of comminuted
central fracture dislocations were transferred to joint
replacement centers for total hip replacement. Three cases
of grade 3 open tibia fractures required full thickness skin
cover before definitive orthopedic procedures. Two cases
required major amputations (one above knee and one below
elbow). One case of fracture dislocation C4-C5 died within
hours of admission.
Discussion
All the patients had been given some sort of first
aid at the site of accident by the meager medical resources
that could reach the site. The effectiveness of such
treatment was doubtful. In fact it was only delaying
evacuation. This makes us rethink the effectiveness of
pre clinical emergency management, fiction or fact? Study
results obtained in trauma patients indicating that total
pre hospital time, including scene time, is correlated to
patient outcome have led to the conclusion that at the
scene treatment by emergency physicians may be
dispensable. It has, however also been demonstrated that

412

INDIAN JOURNAL OF ANAESTHESIA, OCTOBER 2002

the time required for medical treatment at the scene is

equivalent to 20% of the total scene time, thus
representing only a fraction of the total pre hospital
time. Correlating the total pre hospital time or scene
time to outcome therefore appears absurd. The treatment
principle of aggressive shock in poly trauma needs critical
reevaluation on the basis of results obtained by recent
preclinical studies in patients with penetratrating torso
injuries. Small volume resuscitation could not be
demonstrated to improve outcome in polytrauma patients,
although a slight improvement with brain injury may be
assumed. Endotracheal intubation and early artificial
ventilation are proven therapeutic principles in
polytraumatised patients.7
Ghaisal is a small village and evacuation of
casualties to Siliguri required lot of transport and the
distance is 90 kilometers. In Army we use the McPhersons
formula to deal with such problems.
(a)

To find out the time required : T=1/M x W x t/N

(b)

To find out the amount of transport required to

evacuate in a given time :
Where

M =

1/T x W x t/N

M =

Units of transport required or

available

T =

Time allowed

W =

Number of sick and wounded

Time taken by transport for one

journey and return

N =

Number of patients each unit of

transport carries.

By knowing the variables, you can calculate the

number of ambulances required for transportation of
the casualties. In the usual method of allotment of
priorities (triage) threat to life has been the only basis of
allotment of priority; the morbidity potential has not
been given due weightage. Standard acceptable figures
of P-1,P-2,P-3 accounted for 10%, 20% and 70%
cases respectively. In our series there were 11% cases of
P-1, 30% P-2 and 59% P-3 cases. The difference is due
to the fact that we have included open intra articular
fractures in P-1 cases and open fractures and dislocations
in P-2 cases. This has been done due to the fact that
any delay in treatment of open fractures, dislocations
and open intra-articular fractures can result in
considerable morbidity. Comparison of regional
distribution of injuries in various disasters3 is brought
out in Table-6. The difference between our series and
other series can be explained by the vastly different

mechanism of injury in war wounds which are caused by

blasts and projectiles and those caused by sudden
deceleration as seen in the Ghaisal train accident.
Table 6 : Comparison of regional distribution of injuries (3)
INJURY

KOREAN
WAR (%)

INDO-PAK
CONFLICT (%)

158 BH
EXPERIENCE (%)

Head injury

15

01

07.7

Thoracic injury

19

12

13.6

Abdominal injury

11

13

2.9

Upper limb injury

25

22

16.5

Lower limb injury

27

69

32

Anaesthesia for trauma patients is challenging. The

problems were high workload, physical, high psychological
and emotional stress. The moment-by-moment care by
titrating, so crucial for patients with life threatening injuries
is difficult and it should be done with utmost care and
devotion, unmindful of personal comfort.
Missed injuries
Mass casualties present with confusing and
continuously changing situations. Various reasons such as
haemodynamic instability, polytrauma, altered sensorium
and low index of suspicion can contribute to missed
injuries. Table-7 provides considerable figures for
missed injuries in various studies. Wide variation in the
incidence of missed injuries is perhaps due to the absence
of clear-cut guidelines regarding what constitutes a missed
injury.
Table 7 : Comparative figures of missed injuries
STUDY

TYPE
of TRAUMA

No of CASES
MISSED
INJURIES

Albrektesen SB
Thompson JL (1989) (5)

Blunt

218

75(34%)

Chan RNW, Ainscow D

(1980) (4)

Blunt

327

39(12%)

Enderrson BL, Stevens SL

De Boo JM (1990) (6)

Blunt

399

36(11%)

158 BH Experience

Blunt

103

06(5.08%)

Unusual patterns of injuries observed

The high number of casualties received in a short

period of 36 hours

Extrication problems were acute being a railway

accident and was responsible for some of the unusual
pattern of injuries.

(COL.) PRABHAKAR, YOGESH : GHAISAL TRAIN ACCIDENT

The high incidence of grade 3 open tibial fractures

and the use of external fixators
The unusually high number of dislocations of hip
The three cases of closed crush injuries of upper
limbs (All had complete motor loss in upper limbs
without sensory impairment and their subsequent
spontaneous recovery)
The two cases of ARDS
Burns and penetrating injuries were conspicuous by
their absence

References
1. James R. Macho, MD, Frank R. Lewis, Jr., MD, & William
C. Krupski, MD, Management of the injured patient, In:
Lawrence W Way, Editor, Current surgical diagnosis and
treatment, 10th ed. Appleton and Lange, USA, 1994;
213-225.

413
2. Indrayan A, Epidemiology of Trauma deaths in India in
Principles and practice of trauma care (Ed) Kocher SK, Jaypee
Brothers Medical Publishers (P) Ltd, New Delhi, 1998; 1-12.
3. VK Sinha, Management of ballistic injuries in : Principles
and practice of trauma care (Ed) Kocher SK, Jaypee Brothers
Medical Publishers (P) Ltd, New Delhi, 1998; 32-47.
4. Chan RNW, Ainscow D, Sikoski, JM; Diagnostic failures in
the multipl injured, J Trauma 1980, 20: 684-688.
5. Albrektesen SB, Thomson JL., Detection of injuries in
traumatic death. The significance of medico legal autopsy.
Forces Sci Int 1989;42:135-138.
6. Enderson BL, Stevens SL, DeBoo JM et al ; Occult
pneumothorax in blunt trauma. South Eastern Surgical
Congress Napples 1990.
7. Klinik fur anastheiologie der Johannes Gutenberg Universitat
Mainz. Anaesthesist (Germany) Jan 1996: 45 (1), 75-87.

BOOK REVIEW
Book Title

: 1) Anesthesia and co-existing Disease.

Forth Edition 2002. (Indian Print)

print, the book, I am sure, will attract every anaesthesiology

trainee and the practitioner.

Authors

Robert Stoelting, Stephon F Dierdort.

Publisher

Harcourt India Pvt. Ltd. A Elsevier Science

company

Price

Rs. 1475/-

I, on behalf of IJA, congratulate the publishers Harcourt

India Pvt. Ltd., New Delhi, for bringing out such an excellent
tool of education at an affordable price. I recommend this book
for all the learners of anaesthesiology.

The goal of this book as spelt out by the editors is to

provide the readers with Current and Concise descriptions of the
pathophysiology of diseases, and the impact if any on the
management of anaesthesia. More common conditions like
Diabetes, Hypertension, IHD, etc, which every anaesthesiologist
encounters in his day today practice, are described in wider
details whereas the less common ones are discussed, based on
their unique features which have impact on anaesthetic
management.
Optimal use of illustrations, tables, figures, algorithms,
etc make the book easily understandable and more readable.
Each chapter covers the entire aspects of a topic in a concise
manner, right from the introductory information, basic sciences
to recent advances of the topic. The optimally sized and relevant
bibliography is an unique treasure of the book, catalyzing the
reader to approach the original source of information. The language
of the book is simple with consistent theme of narration throughout
the length of the book. This uniform style is quite acceptable for
every reader as every chapter in the book is finally authored by
the editors, though the contributions according to authors have
been sought by many authors.
With the new format, of presentation with newer tables
and illustrations, with distinct economical advantage of Indian

Book Title : 2) Handbook For Anesthesia and

Co-existing Disease Second Edition 2002
(Indian Print).
Authors

Robert K Stoelting and Stephen F Dierdort.

Publisher :

Harcourt India Pvt. Ltd. A Elsevier Science

company

Price

Rs. 275/-

Hand books play a distinct role in providing optimal

anaesthetic patient care. Irrespective of ones seniority or
experience in the field, there is always a need for a reliable
ready reckoner, which in anaesthetic practice is in scarcity.
This hand book, a companion to the widely read, Anesthesia
and Co-existing Disease, provides rapid and accurate information
at the actual site of patient care (i.e. in OTs, ICUs etc.) if
carried in the pocket. The table format of presentation, facilitates
the quick approach to the needed information.
I appreciate and congratulate the efforts of the authors
and the publishers for providing this pocket dictionary of
anaesthesia for a modest price.
- Editor.