Whether caused by the strain of the ER environment on the staff, or unmet patient expectations, aggression is ultimately fuelled by perception, intolerance, misunderstanding and loss of control [12]. Some patient expectations maybe unrealistic in the

ER environment and some of it may be caused by the media. In our case some of the perceptions about the crisis were due to rumours, inaccurate information and faulty reportage by the media. Eruption of violence in the hospital would have brought all response efforts to a halt. Such a situation where the hospital is unable to render any meaningful care to casualties, either because it is itself, consumed by the event (such as war, earthquake or

nuclear disaster) or because it is overwhelmed Opaganib by the sheer volume of casualties, has been termed a Major Medical Disaster [2] and is a situation best prevented. In the heat of the response, patients who had been transferred to the wards following resuscitation in the ER or operation in the OR often had suboptimal subsequent care. This was because attention was focused on the fresh casualties from the continuing influx in the ER at the expense of those said to have been already “stabilized”. The trickle of personnel who were mobilized from outside the hospital as the crises progressed were directed to the ER and OR, leading to neglect of those in SRT1720 the wards. Some of such patients missed their antibiotics, fluids and wound reviews. Some carried nasogastric tubes and catheters

for too long and went for unnecessarily long periods on nil per os. There was near total neglect of patients who were on admission in the wards for other reasons prior to the onset of the crisis. Initial response involved mobilization of personnel from the wards to the ER and this did not begin to reverse till near the medroxyprogesterone end of the crisis, five days later. A unique, if rare category of patients who suffered suboptimal care during this crisis were patients who, developing a medical emergency at home, were able to get to the hospital. Examples include patients with diabetic crises, hypertensive emergencies and other medical emergencies. The care of the trauma patients was prioritized above these patients even when the injuries were not nearly as life threatening. A major contributory factor was the near total absence of internists as part of the disaster response in the erroneous belief that a mass casualty situation called for the mobilization of only surgeons. Some protocols propose that hospital call-in plans should focus on doctors in the surgical specialties and that the inclusion of internists should only occur as a last resort [14]. While this is certainly reasonable, we found we had occasional need for the services of internists because of prolonged duration of the disaster and therefore, response.