A major earthquake devastated the Armenian Republic of the Soviet Union on December 7, 1988, resulting in thousands of deaths and injuries. In a postearthquake investigation of three towns seriously affected by the earthquake, we studied earthquake-related injury patterns, made observations on rescue and medical efforts, and postulated certain factors associated with increased morbidity and mortality. Information was obtained from official Soviet documents, interviews with survivors of the earthquake, and interviews with local, regional, and national government officials. Figures were based on assessments made by these officials in the field in the immediate postearthquake period. Out of a population of 8,500, there were 4,202 (49.4%) deaths and 1,244 (14.6%) injured (casualty rate, 64.0%). Deaths and injuries were 67 and 11 times higher, respectively, among trapped than nontrapped victims. Being outside at the time of the earthquake or having escaped to the outside from the collapsing structure was crucial for survival. Among persons found alive, 89% were rescued during the first 24 hours, mostly without the use of heavy equipment. This observation underscores the importance of swift rescuer response. As with all field surveys after disasters, there were methodological limitations to this study due to chaotic postearthquake conditions. Accordingly, results must be approached with caution. Nonetheless, these preliminary observations are striking and have generated several new hypotheses for further investigations using more sophisticated analytic methods.

1. ORIGINAL CONTRIBUTION
earthquake;
injury, prevention
The 1988 Earthquake in Soviet Armenia:
A Case Study
A major earthquake devastated the Armenian Republic of the Soviet Eric K Noji, MD, MPH, FACEP*
Union on December 7, 1988, resulting in thousands of deaths and injuries. Gabor D Kelen, MD, FRCP(C), FACEP*
In a postearthquake investigation of three towns seriously affected by the Haroutune K Armenian, MD, DrPHt
earthquake, we studied earthquake-related injury patterns, made obser- Baltimore, Maryland
Ashot Oganessian, PhD§
vations on rescue and medical efforts, and postulated certain factors asso- Soviet Socialist Republic of
ciated with increased morbidity and mortality. Information was obtained Armenia, USSR
from official Soviet documents, interviews with survivors of the earth- Nicholas P Jones, PhD~
quake, and interviews with local, regional, and national government offi- Keith T Sivertson, MD*
cials. Figures were based on assessments made by these officials in the Baltimore, Maryland
field in the immediate postearthquake period. Out of a population of
8,500, there were 4,202 (49.4%) deaths and 1,244 (14.6%) injured (casualty From the Department of Emergency
rate, 64.0%). Deaths and injuries were 67 and 11 times higher, respectively, Medicine, The Johns Hopkins Hospital
among trapped than nontrapped victims. Being outside at the time of the and School of Medicine;* the Department
earthquake or having escaped to the outside from the collapsing structure of Epidemiology, School of Hygiene and
was crucial for survival. Among persons found alive, 89% were rescued Public Health,t and the Department of
during the first 24 hours, mostly without the use of heavy equipment. Civil Engineering]- The Johns Hopkins
University, Baltimore, Maryland; and the
This observation underscores the importance of swift rescuer response. As Computer information Center, Ministry of
with all field surveys after disasters, there were methodological limita- Health, Soviet Socialist Republic of
tions to this study due to chaotic postearthquake conditions. Accordingly, Armenia, USSR.§
results m u s t be approached with caution. Nonetheless, these preliminary
observations are striking and have generated several n e w hypotheses for Received for publication December 21,
further investigations using more sophisticated analytic methods. [Noji 1989. Accepted for publication March 5,
EK, Kelen GD, Armenian HK, Oganessian A, Jones NP, Sivertson KT: The 1990.
1988 earthquake in Soviet Armenia: A case stud~z Ann Emerg Med August
1990;I9:891-897.] Presented at the Society for Academic
Emergency Medicine Annual Meeting in
INTRODUCTION San Diego, May 1989.
During the past 20 years, earthquakes have caused more than a million
deaths worldwide. Better epidemiological knowledge of the causes of death This study was supported by the National
and the type of injuries and illnesses caused by earthquakes is clearly es- Center for Earthquake Engineering
sential for determining appropriate relief supplies, equipment, and person- Research (Project No. 884005C), The
nel. l-4 On December 7, 1988, an earthquake registering 6.9 on the Richter Armenian Relief Society, and the Office of
scale hit the northern part of the Armenian Soviet Socialist Republic, one US Foreign Disaster Assistance/Agency for
of the most seismically active regions of the Soviet Union s-s {Figure 1). International Development.
Caused by movement along a geological fault near the town of Spitak in
the northwestern part of the country, the quake affected 40% of the na- Address for reprints: Eric K Noji, MD,
tional territory.9,1o Of the 150 villages damaged, 58 were destroyed. A high MPH, FACER Department of Emergency
Medicine, The Johns Hopkins Hospital,
percentage of Armenia's housing (11%) was destroyed or rendered uninhab- 600 N Wolfe Street, Baltimore, Maryland
itable, and 500,000 to 700,000 persons were made homeless, t~ Bridges, life- 212O5.
lines (eg, water, power, gas, sewage systems), and industrial facilities were
also severely damaged. 1~ The toll in human terms was devastating: approx-
imately 40,000 persons were reported trapped in collapsed buildings -
15,000 were successfully rescued, and 25,000 bodies were recovered from
the rubble. Another 31,000 were known to be injured, of whom 12,200
required hospitalization. ~1,13
We undertook this survey during the period immediately after the earth-
quake to assess the epidemiologic impact of the disaster and to develop an
understanding of the relationships among building characteristics, occu-
pant actions, search and rescue, medical care, and patient outcome.
19:8 August 1990 Annals of Emergency Medicine 891/75

2. EARTHQUAKE
Noji et al
• Tbilisi
. . . . EPICENTER
USSR
keninakan',• • Kirovakan
_ __ • Yerevan
s,•
¢ •. a,.I
TURKEY ,--) ,, "" t
! •
w N
! o: .... ,o wm /0. IEPICENTER| STEPANAVAN
• ~ ,,
h:j,oo I ,.
¢l ,~., ;
£~-- .a,
, o ) o{ ~ z40~ ~ -- , ~6 , ' ' ,
// ~ , ~ o .9 / .... " ", ' ~, '~' ' l~-
Conlou¢ 200 m
FIGURE 1. Caucasus region and ma- damages and loss, and make observa- tained from the A r m e n i a n State
jor cities affected by earthquake. In- tions on rescue and medical care ef- C o m m i t t e e for Construction (Gos-
set: Region of most severe damage. forts. C e n s u s i n f o r m a t i o n , t o t a l stroi) and the Armenian Scientific
deaths, and total injured were ob- Research Institute of Civil Engineer-
tained from local health officials, the ing and Architecture. Observations
METHODS regional military disaster command on medical and rescue efforts were
The population under study was station, and the local headquarters of obtained from interviews with army,
the inhabitants of three towns within the Armenian Republican Civil De- civil defense, and Ministry of Health
the rural areas most affected by the fense. Special units of the Ministry of officials as well as with local fire-
earthquake, covering an area of 80 Internal Affairs were responsible for fighters, militiamen, army personnel,
k m : in northwest Armenia (Figure 1). organized registration of deaths, in- disaster relief workers, and surviving
Criteria applied to select the commu- cluding cause of death, place of en- inhabitants of the region.
nities for inclusion in the study were trapment, and time of extrication. An There were significant problems
population less than 5,000 and seis- office was set up in Spitak by the concerning the collection of data in
mic intensity of IX or greater on the Ministry of Internal Affairs for per- this study; these difficulties have
Modified Mercalli scale. Three towns sons seeking information on missing plagued all previous attempts to in-
- N a l b a n d , Geghasar, and Kat- friends and relatives. v e s t i g a t e h e a l t h effects of earth-
natschur - met the above criteria. Countrywide morbidity and mor- quakes in the immediate postimpact
All three towns were within 5 km of tality statistics were obtained from period.3,4,14 The chaotic postearth-
the earthquake's epicenter. The total the government Commission of the quake conditions as well as an under-
population of these three towns was Armenian SSR and the Division of standable emphasis on operational
approximately 8,500 before the earth- Information Systems of the Arme- concerns precluded the ability of au-
quake. nian Ministry of Health. Information thorities to conduct a systematic sur-
A rapid reconnaissance mission on housing and structural charac- vey of residences and households in
was conducted seven days after the teristics of buildings damaged or de- these three towns. A l t h o u g h the
earthquake to collect data, assess stroyed by the earthquake was oh- Ministry of the Interior reported that
76/892 A n n a l s of E m e r g e n c y Medicine 19:8 August 1990

3. TABLE 1. Location of individuals and entrapment status: Association w~th death and injury
Relative Risk Relative Risk
Population Deaths (%) (95% CI) Survivors Injured (%) (95% CI)
Location of
Individuals
Outside 651 8.8 1.0 594 1.7 1.0
Inside 7,120 55.1 6.3 (5.4-7.4) 3,197 36.3 21.6 (15.1-30.9)
Unknown 729 30.5 507 14.6
Total 8,500 49.4 4,298 28.9
Nontrapped Persons 3,390 1.2 1.0 3,349 8.8 1.0
q-rapped Persons 5,110 81.4 67.3 (49.7-91.3) 949 100.0 11.4 (10.2-12.7)
CL, confidence interval.
F I G U R E 2. Main street in Nnlband
showing complete collapse of all
buildings. Note complete collapse of
precast-concrete frame school build-
ing on right side of street.
same groups (Table l). Thus, deaths
w e r e 67 t i m e s and i n j u r y rates 11
times higher among trapped than
nontrapped victims. The casualty
rates w e r e reported to be 100% for
t r a p p e d people as c o m p a r e d w i t h a
rate of 9.9% for n o n t r a p p e d individ-
uals. For those trapped, the ratio of
injuries to deaths was 0.23, whereas
for n o n t r a p p e d i n d i v i d u a l s , it w a s
7.2.
All b u i l d i n g s in t h e t h r e e t o w n s
sustained severe damage or c o m p l e t e
collapse. A l m o s t all of the residential
dwellings were one-story unrein-
a strict registration of all deaths, in- RESULTS forced stone m a s o n r y structures b u i l t
cluding c i r c u m s t a n c e s of death, had In the three towns, the crude death from carved b l o c k s of tuff {a light-
b e e n c o n d u c t e d , all s t a t i s t i c s pre- r a t e ( t h e p e r c e n t a g e of r e s i d e n t s weight, volcanic stone) set in m o r t a r
sented here should be considered ap- found dead on extrication) was to form walls. Most of these dwell-
p r o x i m a t i o n s and, in some cases, an- 49.4%, w i t h a crude injury rate of ings p a r t i a l l y or t o t a l l y c o l l a p s e d .
ecdotal. For example, p o p u l a t i o n fig- 28.9% and an overall c a s u a l t y rate There were two types of precast con-
ures for the three t o w n s were taken (deaths and injuries) of 64.1% (Table crete b u i l d i n g s in the t h r e e towns.
from a census conducted in i979. It 1). At the t i m e of the impact, m o s t P r e c a s t c o n c r e t e e l e m e n t s refer to
is u n k n o w n w h a t p e r c e n t a g e of (83.8%) of the people were indoors. concrete structural c o m p o n e n t s t h a t
households were interviewed or how The m o r t a l i t y rate was significantly have been fabricated at a factory and
s y s t e m a t i c a l l y the survey was carried greater for these individuals (55.1%) then transported to the c o n s t r u c t i o n
out. Unfortunately, we were not able t h a n for t h o s e w h o w e r e o u t d o o r s site for erection compared with
to d e t e r m i n e the n u m b e r of persons (8.8%) (P < .01) (Table 1). Injury rates poured-in-place concrete elements.
successfully extricated who died w e r e also s i g n i f i c a n t l y g r e a t e r for M o s t i n d u s t r i a l f a c i l i t i e s in t h e
later. those i n s i d e (36.3%) t h a n for t h o s e t o w n s s t u d i e d were of t h e precast-
T h e data were a n a l y z e d w i t h the outside (1.7%)(P < .01)(Table 1). c o n c r e t e f r a m e type, c o n s i s t i n g of
aid of the Statistical Analysis System Of t h e t o t a l p o p u l a t i o n , 60.1% precast concrete c o l u m n s and b e a m s
(SAS Institute, Cary, N o r t h Carolina). were reported to have been trapped. w e l d e d or t i e d t o g e t h e r to f o r m
The analyses included relative risk D e a t h rates were 81.4% for t r a p p e d frames (Figure 2); there was a s m a l l e r
c a l c u l a t i o n s and X2 tests of propor- individuals as c o m p a r e d w i t h a rate i n v e n t o r y of p r e c a s t - c o n c r e t e p a n e l
tion for simple comparisons. Statisti- of 1.2% for t h o s e w h o w e r e n o t s t r u c t u r e s . Of t h e s e t h r e e t y p e s of
cal significance was considered at P trapped (P < .01). Injury rates were b u i l d i n g systems, p o o r l y r e i n f o r c e d
< .05. 100% and 8.8%, respectively, for the or unreinforced stone m a s o n r y build-
19:8 August 1990 Annals of Emergency Medicine 893/77

4. EARTHQUAKE
Noji et al
TABLE 2. Effect of building type on survival m Nalband
Death
Building Type Buildings Occupants Rate Relative 95% Confidence
(%) (N) Risk Interval P
Stone masonry 38 415 12.8 (53) 1.0
Precast concrete panel 2 40 47.5 (19) 3.7 2.46 - 5.61 < .01
Precast concrete frame 8 577 87.0 (502) 6.8 5.29 - 8.78 < .01
Total 48 1,032 55.6 (574)
FIGURE 3. Live rescues as a function
of time after impact (total numbers
and cumulative percentage). Live Rescues Cumulative %
ings performed most poorly in terms !100
of n u m b e r of complete and partial 300
collapses.
According to statistics collected by
the A r m e n i a n Ministry of Internal
Affairs and the State Committee for
Construction, most of the fatalities
occurred in the collapse of these
stone m a s o n r y buildings (Table 2).
Precast-concrete frame type build-
'°°f
200
100
50
ings, however, were associated with
highest mortality per building. De- 0 "0
tailed statistics were available for 0 6 12 18 24 48 72 96 120 144 168
eight buildings of this type in Nal- Hours After Impact
band. Eighty-seven percent of the oc-
cupants were killed (Table 2). The
risk of death was 6.8 times greater in Live rescues ~ Cumulative %
these eight frame buildings than in *Data from Nalband, Katnatschur, and Geghasar.
stone m a s o n r y buildings based on
this limited sample (P < .01). In the 3
sample of precast frame buildings,
two of the structures that collapsed
resulted in an exceptionally high rate throat, and respiratory passages of Search and Rescue
of mortality. One was a sewing fac- these victims, suggesting that airway Rescue work was m o s t difficult
tory with 212 workers, of whom 205 obstruction and asphyxiation from during the first night when electric-
(97%) died. The other was a school dust were the causes of death. This ity and lights were unavailable; these
w i t h 302 children, of w h o m 285 forensic evidence was corroborated efforts had to be halted at several lo-
(94%) died. T h e p r e c a s t - c o n c r e t e by interviews with local residents of cations until the next morning. Oper-
panel buildings were also more lethal Nalband, who described large and ations in these three towns were
than the stone masonry structures (P dense dust clouds created by pulver- c o m p l i c a t e d by absence of street
< .01). ization of the stone and concrete markings, maps, and building plans.
Of 240 patients reported by the walls of falling buildings. Destroyed villages and small towns
Ministry of Health to be evacuated Data collected 14 days after the were isolated by numerous landslides
from the three towns, 23 (9.6%} de- earthquake on 4,832 patients admit- and impassable roads, which delayed
veloped crash syndrome as a result of ted throughout hospitals in Armenia r e l i e f t e a m s and p r e v e n t e d full
limb compression, and 11 {4.6%) de- (Table 3) showed that combination knowledge of the extent of the disas-
veloped secondary acute renal failure injuries constituted 1,918 (39.7%)of ter f r o m reaching the authorities.
requiring renal dialysis. All evacu- the cases. Superficial trauma such as Most of the initial rescue work and
ated patients were reported to suffer lacerations and contusions were the medical relief was carried out en-
from varying degrees of hypothermia. m o s t frequently observed (24.9%), tirely by local inhabitants. Of the 240
P o s t m o r t e m e x a m i n a t i o n s of eight f o l l o w e d by h e a d injuries (22%), trapped victims who were evacuated
victims removed from the site of a lower-extremity injuries (19%), crush for medical care in Yerevan, local
b u i l d i n g c o l l a p s e r e v e a l e d large syndrome (11%), and upper-extremity Civil Defense workers reported that
amounts of dust in the nasal cavities, trauma (10%). 228 (95%) were extricated by inhabi-
78/894 Annals of Emergency Medicine 19:8 August 1990

5. FIGURE 4. Patients presenting for
emergency care at Erebuni Hospital
Patients in Yerevan.
300 I
Nalband, the great majority of those
2OO rescued alive from collapsed build-
ings (89%} were extricated during the
first 24 hours (Figure 3). The proba-
bility of being extricated alive from
the debris declined sharply over
time. There were no live rescues af-
0 ter day 6.
0 1 2 3 4 5 6 7 8 9 10 11
Emergency Medical Care
Days 4 Many of the surviving injured vic-
tims (30%) received no on-site medi-
cal assistance. No individuals were
k n o w n to have received any ad-
TABLE 3. Distribution of hospitalized injuries by site a s reported to the vanced on-site medical care, such as
Ministry of Health of Armenia after the December 7, 1988, cervical-spine immobilization, ad-
earthquake ministration of oxygen or IV fluids,
or tracheal intubation. Most of the
patients were transported in private
Injury N % vehicles with no in-transit advanced
Head or face 1,040 22.0 medical care. Because all of the hos-
pitals in the region were severely
Skull, facial fractures 130 2.7 damaged and many medical person-
Brain concussion 417 8.6 nel were either killed or injured (esti-
Other internal head trauma 173 3.6 mated to be 80%), 311 of the injured
(25%) were transported to hospitals
Open head or facial wounds 320 6.6 in unaffected parts of Armenia or to
neighboring Soviet Georgia (informa-
Upper extremities 475 10.0 tion provided by Ministry of Health).
Upper-extermity fractures 265 5.5 Unfortunately, winter weather condi-
Traumatic amputations, arms 197 4.1 tions hampered aeromedical evacua-
Elective amputation, arms
tion of the injured. Damage to rail-
13 0.3
ways, extraordinary traffic conges-
Lower extremities
tion, and impassable roads due to
915 19.0
mud made ground evacuation diffi-
Lower-extremity fractures 584 12.1 cult. Ground transport times to re-
©pen wounds, legs 102 2.1 ceiving hospitals in Yerevan, 75 k m
Traumatic amputations, legs 170 3.6 away, were often as long as five
hours.
Elective amputation, legs 59 1.2 In Yerevan, several hospitals ad-
mitted a large number of casualties
Superficial trauma 1,203 24.9 in the days immediately following
the earthquake. Erebuni Hospital, a
Crush syndrome 533 11.0 1,000-bed facility in Yerevan, treated
902 patients in the first 11 days after
Other 633 13.1 the earthquake, 80% of whom were
admitted during the first five days
(Figure 4). Only 22 of the 902 pa-
tants of the three villages them- fense units stationed nearby, fol- tients (2.4%) requiring hospitaliza-
selves. T h e m o s t s o p h i s t i c a t e d lowed a few days later by volunteer tion at Erebuni Hospital as a conse-
m e a n s of e x t r i c a t i o n used were teams from less-affected areas. Heavy quence of the earthquake were ad-
hands, shovels, picks, and farming rescue equipment such as cranes and mitted seven or more days after the
tools. bulldozers did not arrive in Nalband impact.
External assistance did not arrive until day 5. An operations headquar-
in Nalband for the first 24 hours, and ters was not established in Nalband DISCUSSION
Katnatschur and Geghasar did not re- until December 18, 11 days after the Although the risk of catastrophic
ceive aid until days 3 and 4, respec- earthquake. earthquakes is widely recognized in
tively. The first outside relief According to information provided parts of California, few people realize
consisted of military and civil de- by the local army command center in that in the past 300 years, the eastern
19:8 August 1990 Annals of Emergency Medicine 895/79

6. EARTHQUAKE
Noji et al
U n i t e d States has suffered eight survey of three building types in a survey of 3,619 survivors showed
earthquakes of similar or greater Nalband (eg, stone masonry, precast- that 93% of those who were trapped
m a g n i t u d e than that in Armenia. concrete panel, and precast-concrete and survived were extricated within
There is a high probability that a ma- frame) showed death rates of 12%, the first 24 hours. As suggested by
jor earthquake will hit the eastern 46%, and 87%, respectively, suggest- our data, if any significant reduction
United States in the next several de- ing that the type of building and col- in e a r t h q u a k e m o r t a l i t y is to be
cades. Building damage and life loss lapse pattern affect survival rates achieved, attention should be given
in such an event is predicted to be se- (Table 2). to appropriate search and rescue ac-
rious and widespread due to lack of Infill masonry, panels, and bricks tion within the first two days after
seismic codes and absence of earth- often fell off, killing persons both in- the impact.
quake preparedness programs. Other side and outside, and the frequent In the Italian study cited above,
states, such as Utah and Washington, collapse of stairways made it partic- 95% of the deaths recorded were
are also at risk from earthquakes, and ularly difficult for people to escape among those trapped in rubble who
despite recognition of the threat, mit 2 because many of these buildings had died before extrication. 22 Estimates
igation activities in these areas are only one stairway. In all three build- of survivability among entrapped vic-
inadequate. ing types, the collapse of nonstruc- tims buried under collapsed earthen
Past studies have stressed the im- tural e l e m e n t s s u c h as p a r a p e t s buildings in Turkey and China indi-
portance of critically analyzing earth- caused many serious injuries. The to- cate that within two to six hours,
quakes to develop methods of rapidly tal collapse ("disintegration") of the less than 50% of those buried are
assessing health-care needs and im- precast-concrete frame buildings was still alive.22, 2,~ Although it is not pos-
proving disaster relief.15 Epidemio- associated with particularly high sible to determine whether a trapped
logic studies on earthquake-related mortality rates (more than 90%) be- person died immediately or survived
injuries have indicated that a quan- cause the characteristic failure pat- for some time under the debris, it is
titative relationship may exist be- tern of this type of c o n s t r u c t i o n undoubtedly true that more people
tween morbidity and mortality.~6, t7 greatly complicated the search and might have been saved if they had
For example, in the Guatemala and rescue effort and reduced signifi- been extricated sooner. Safar, study-
Nicaragua earthquakes, the ratio of cantly the opportunity for occupant ing the 1980 earthquake in Italy, 2s
injured to dead was 3:1. In the area of survival. concluded that 25% to 50% of vic-
Armenia studied here, this ratio was We observed that the fragmenta- tims who were injured and died
reversed, that is, three dead for every tion of the floor system resulted in slowly could have been saved if ini-
person injured. This suggests the ex- very tight packing of the rubble with tial life-saving first aid had been ren-
traordinary lethality of the Armenian no cavities or "void spaces" for possi- dered immediately.
event. ble survival of victims. The distribu- There were major problems with
The Armenian earthquake was of tion and amount of void space in the extrication of trapped v i c t i m s be-
lesser magnitude than the 1989 Loma collapsed structure and the most cause of lack of adequate equipment
Prieta e a r t h q u a k e in C a l i f o r n i a . likely locations of those voids arc and trained rescue personnel. Pene-
However, its consequences were in- important in locating and rescuing trating concrete slabs and cutting
comparably greater, primarily be- trapped people quickly. Such infor- through columns and beams of the
cause of the design and quality of m a t i o n m a y help to guide future p r e c a s t - c o n c r e t e frame buildings
construction of buildings in the area. search and rescue o p e r a t i o n s by proved to be major obstacles in the
The primary cause of death, injury, pointing out those collapsed build- local rescue effort. No cutting tools
and destruction was the total col- ings that have the greatest proba- were available, and the tools that
lapse of buildings that were not ade- bility of containing survivors and by were available proved to be ineffec-
quately designed for earthquake re- indicating the location of likely void tive. The number of people available
sistance. spaces. to help rescue others was greatly re-
Past studies have shown that fac- As might be expected, entrapment duced because of the very high per-
tors determining the number of peo- appears to be the single most signifi- centage of people trapped and killed.
ple killed after a building collapses cant factor associated with death or This scarcity of rescue workers may
include entrapment, severity of their injury. Death rates were 67-fold and have contributed to the excessively
injuries, how long they can survive injury rates more than ll-fold those high mortality in the three towns ex-
without medical attention, and time for trapped than nontrapped people. amined. Most of the search and res-
to rescue and medical treatment.t8-2o Death rates for those inside greatly cue effort was late and, even at the
A 1977 s t u d y on the G u a t e m a l a exceeded those for persons outside; peak of activity, was seriously inade-
earthquake concluded that deaths more than 80% of those trapped died. quate.
and injuries are critically dependent This earthquake substantiated that In the three towns visited during
on housing damage and construction response time for search and rescue our reconnaissance mission, very lit-
materials used. 21 Results reported in is absolutely critical. Our observa- tle in the way of basic medical care
our study carry this concept further tion that the proportion of people was administered to persons who had
by suggesting that different building found alive declined with increasing been located and were actively being
types and structural systems have delay in extrication parallels the ob- extricated from the debris. The provi-
different collapse mechanisms and servations made in Italy after the sion of basic supportive care, such as
patterns of cavity formation when C a m p a n i a - I r p i n i a e a r t h q u a k e in IV fluids, might have gone a tong way
they fail under the influence of earth- 198022`23 and the Tangshan earth- toward reducing morbidity and mor-
quake ground motion. The limited quake in 1976. 24 In the Italian study, tality, particularly in preventing the
80/896 Annals of Emergency Medicine 19:8 August 1990

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19:8 August 1990 Annals of Emergency Medicine 897/81