대한응급의학회지제 28 권제 1 호 Volume 28, Number 1, February, 2017 Disaster 경주마우나오션리조트내체육관붕괴사고의재난의료대응체계고찰 차명일 1 김기운 2 김주현 3 좌민홍 4 최대해 5 김인병 1 왕순주 6 유인술 7 윤한덕 8 이강현 9 조석주 10 허탁 11 홍은석 12 원저 이차게재 명지병원응급의학과 1, 순천향대학교부천병원응급의학과 2, 인제대학교서울백병원응급의학과 3, 연세대학교세브란스병원재난의료교육센터 4, 동국대학교경주병원응급의학과 5, 한림대학교동탄성심병원응급의학과 6, 충남대학교병원응급의학과 7, 국립중앙의료원중앙응급의료센터 8, 연세대학교원주의과대학응급의학과 9, 부산대학교병원응급의학과 10, 전남대학교병원응급의학과 11, 울산대학교병원응급의학과 12 A Study on the Disaster Medical Response during the Mauna Ocean Resort Gymnasium Collapse Myeong-il Cha, M.D. 1, Gi Woon Kim, M.D. 2, Chu Hyun Kim, M.D. 3, Minhong Choa, M.D. 4, Dai Hai Choi, M.D. 5, Inbyung Kim, M.D. 1 *, Soon Joo Wang, M.D. 6, In Sool Yoo, M.D. 7, Han Deok Yoon, M.D. 8, Kang Hyun Lee, M.D. 9, Suck Ju Cho, M.D. 10, Tag Heo, M.D. 11, Eun Seog Hong, M.D. 12 Department of Emergency Medicine, Myongji Hospital, Goyang 1, Department of Emergency Medicine, Sooncheonhyang University Bucheon Hospital, Bucheon 2, Department of Emergency Medicine, Seoul Paik Hospital, Inje University College of Medicine, Seoul 3, Center for Disaster Relief Training and Research, Severance Hospital, Yonsei University College of Medicine, Seoul 4, Department of Emergency Medicine, Dongguk University Gyeongju Hospital, Gyeongju 5, Department of Emergency Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong 6, Department of Emergency Medicine, Chungnam National University Hospital, Daejeon 7, National Emergency Medical Center, National Medical Center, Seoul 8, Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju 9, Department of Emergency Medicine, Pusan National University Hospital, Pusan 10, Department of Emergency Medicine, Chonnam National University Hospital, Gwangju 11, Department of Emergency Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan 12, Korea Purpose: To investigate and document a disaster medical response during the collapse of the Gyeongju Mauna Ocean Resort gymnasium, which occurred on February 17, 2014. Methods: The official records of each institution were verified to select the study population. All the medical records and emergency medical service records were reviewed by an emergency physician. Personal or telephonic interviews were conducted without a separate questionnaire if the institutions or agencies crucial to disaster response did not have official records or if information from different institutions was inconsistent. Results: One hundred fifty-five accident victims, who were treated at 12 hospitals mostly for minor wounds, were included in this study. The collapse killed 10 people. Although the news of the collapse was disseminated in 4 minutes, it took at lease 69 minutes for a dispatch of 4 disaster medical assistance teams to take action; 4.5% of patients were treated on-site, 56.7% were transferred to 2 nearest hospitals, and 42.6% were transferred to hospitals with poor preparation to handle disaster victims. 책임저자 : 김인병경기도고양시덕양구화수로 14번길 55 명지병원응급의학과 Tel: 031-810-7119, Fax: 031-810-7129, E-mail: kiminbyung@gmail.com 접수일 : 2016년 7월 13일, 1차교정일 : 2016년 7월 14일, 게재승인일 : 2016년 8월 16일 이논문은 Clin Exp Emerg Med 2016 Vol (3) No (3) 에보고된연구에기초한것임. 97
98 / 차명일외 Conclusion: In the collapse of the Gyeongju Mauna Ocean Resort gymnasium, the initial triage and distribution of patients were inefficient, with delayed arrival of medical assistance teams. These problems had also been noted in prior mass casualty incidents. Government agencies are implementing improvements, and this study could aid the implementation process. Key Words: Disasters, Mass casualty incidents, Medical assistance, Social networking Article Summary What is already known in the previous study Although published reports on previous disasters have pointed out the absence of initial field triage or insufficient hospital transport dispersion, no significant improvements have been made. What is new in the current study The Mauna Ocean Resort gymnasium collapsed on February 17, 2014, at 21:06. This was a mass casualty incident with at least 155 casualties. Field triage and distribution of transportation at the site were not properly conducted, like other previous disasters. However, this highlighted a need for public safety and practical preparation in the form of a disaster response system. 며다른하나는세월호침몰사고이다. 이두가지사건은재난대응체계뿐아니라사회전반에 안전 에대한일반시민들의경각심을일깨워준사건이었다. 이제까지학회에보고된다수사상자발생사고에대한재난의료측면에서의논문들에서는초기현장중증도분류부재, 이송병원분산의미흡함등의문제점들을반복하여지적하고있으나개선되지않고있었다 1-8). 이번사고에서도이전의문제점들이그대로반복되었다는언론의지적을받았다 9,10). 경주마우나오션리조트내체육관붕괴사고는 2014년 2 월 17일발생하였다. 9일후대한응급의학회에서는조사위원회를구성하였고, 사고에대해재난의료의관점에서조사하고기록하여향후재난의료체계발전을위한참고자료로활용하고, 재난의료체계의정책개선방향을제시하기로하였다. 조사에는사고당시구급대원을비롯한소방, 재난의료지원팀 (disaster medical assistance team, DMAT), 보건소, 의료기관, 정부기관의재난의료대응을포함하였다. 본연구는이러한조사결과를요약하였다. 서론 2014년은한국의재난대응체계에대해큰교훈을안겨준두가지사건이발생한해이다. 하나는 2014년 2월 17 일발생한경주마우나오션리조트내체육관붕괴사고이 대상과방법 1. 연구대상서론에서기술한바와같이본사고의사상자는기관에따라집계결과가달랐으나, 사망자수는같았다. 이문제 Table 1. Hospital investigation Regions Hospitals No. of medical records No. EMS run sheets Type of interview Ulsan Metropolitan City Hospital A 39 23 Personal Hospital B 43 23 Personal Hospital C 08 06 - Hospital D 04 04 - Hospital E 03 Not provided Personal Gyeongju city Hospital F 17 No patient Personal Hospital G 08 03 Personal Hospital H 08 No patient Personal Hospital I 06 No patient Personal Busan Metropolitan City Hospital J 20 No patient - Hospital K 03 No patient - EMS: emergency medical service
Mauna Ocean Resort Gymnasium Collapse / 99 를해결하고자소방의공식결과보고서에기재된 115명의환자를먼저조사하였고, 중앙응급의료센터의결과보고서에기재된환자를추가로조사하였다. 환자가이송된 19개병원중 11개병원의의무기록을조사할수있었다. 또한소방서구급활동일지에는이송기록이있으나병원진료를받지않고귀가하여의무기록이없었던환자도조사대상에포함하였다. 환자가병원간전원을거쳐중복된경우도있어이를최대한배제하여총 12개병원의 155명의환자를확인하고본논문의조사대상으로하였다. 2. 연구설계와데이터수집사고당시의재난대응에대해각기관별대응을종합적으로분석하고자각기관의공식결과보고서를분석하였다 11,12). 발표자가재난대응에직접참여하였으나발표자료가공식보고서내용에포함되지않은경우, 그들의대한응급의학회춘계학술대회, 대한재난의학회학술대회발표자료 를조사자료에포함하였다. 의무기록의경우 12개병원중 11개병원의의무기록을후향적으로조사하였다 (Table 1). 구급활동일지는 119 구급차로이송한환자가없는 4개병원과, 기록을제공하지않은 1개병원을제외한 5개병원에서보관중인사본을후향적으로조사하였다 (Table 1). 의무기록에서는내원시각, 중증도분류결과, 내원수단, 내원시활력징후, 진료결과, 주증상, 진단명, 검사및처치내역, 퇴실시각, 입원여부등을조사하였고, 구급활동일지에서는현장도착시각, 병원도착시각, 중증도분류결과, 구급차소속, 이송병원, 활력징후, 주증상, 응급처치내역등을조사하였다. 모든의무기록과구급활동일지는한명의응급의학과전문의가검토하였다. 인터뷰는사고당시재난대응에참여했던정부기관, 소방및병원등을대상으로직접방문또는전화로진행하였다. 공식결과보고서가작성되지않은보건복지부, 국민안전처, 경주시보건소의경우인터뷰를진행하였다. 경주시 Table 2. Investigation summary as per the disaster response stages Stages Recognition of the accident, propagation of the situation, and dispatch of advanced medical post/dmat Field disaster medical activity Inpatient care at the hospital DMAT: disaster medical assistance team Investigation points Time of accident information Path of accident information Time of identifying the scale of casualties Propagation path of the situation Time of dispatch request Path of dispatch request Decision-making of the dispatch Dispatch decision time Dispatch preparation time Dispatch time Scene arrival time Dispatch equipment and personnel Field triage, first aid, and hospital selection Command system of advanced medical post Field disaster medical activity report system communication tool Field access control Inquiry path to determine the status of hospital beds Field propagation path of transportation guidelines Time of hospital arrival Triage results Means of hospital arrival Initial vital signs Treatment outcome Diagnosis Major examinations and treatment Status of hospitalization Days of hospital stay Medical staff activation time Response to multiple casualties
100 / 차명일외 에위치한 4개병원, 가장많은환자를진료한 2개병원, 사고현장과가장가까이위치한권역외상센터의의료진과직원을인터뷰하였다. 현장에서의의료활동을조사하기위해, 또한공식결과보고서간내용이다른경우이에대한확인을위해 DMAT, 지역응급의료지원센터를포함한중앙응급의료센터, 민간이송업구급차직원을인터뷰하였다. 별도의질문지는사용되지않았고 Table 2에기재된항목에대해질문을주고답변을수집하였다. 3. 통계분석환자의중증도분류결과에대해병원기록에서중증도분류결과를다확인할수없어외상환자의중증도를평가할수있는 Injury Severity Score (ISS) 를사용하기로하였다. 의무기록의정보만으로는산출이불가능하여진단코드 International Classification of Diseases version 10 (ICD-10) 기반으로한 Excess Mortality Ratio-adjusted ISS (EMR ISS) 를사용하였다 13). 결과경주마우나오션리조트내체육관붕괴사고는 2014년 2월 17일 21시 6분경상북도경주시양남면동남로 1021 마우나오션리조트에서발생하였다 11). 10일간계속해서내린폭설로인하여체육관지붕이누적된눈의하중을견디지못하고무너진것이원인으로지목되었다. 당시체육관에는부산외국어대신입생오리엔테이션이진행중이었으며, 참가자중 400여명은자력대피하였다. 리조트로접근하는산길은제설작업이이루어지지않은데다가 1차선도로여서차량의접근도어려웠고, 눈이계속내리는날씨와 2.8도의추운기온으로구조작업은더욱어려웠다. 시간대별로구조와구급활동을정리하면 Table 3과같다. 1. 사고인지와대응 2014년 2월 17일 21시 06분최초의신고전화를접수한경상북도소방재난본부종합상황실에서는 21시 10분구급상황관리센터를통해경상북도지역응급의료지원센터로상황을전파하였다. 지원센터에서는 21시 16분중앙응급의료센터로먼저상황을전파하였고, 중앙응급의료센터에서는 21시 30분보건복지부로상황을전파하였다. 울산과대구지역응급의료지원센터 ( 울산대학교병원및경북대학교병원 DMAT과같음 ) 에는 22시에상황을전파하며 DMAT 출동대기를요청하였다 (Fig. 1). 경상북도의공식 DMAT은안동병원이보유하고있지만, 재난현장에서가까운팀은울산과대구에위치하기때문이다. 한편경상북 도소방재난본부종합상황실에서는경주시청으로 21시 11분에상황을전파하였고, 21시 37분경주시장이경주시보건소장에게상황을전파하였다 ( 경주시보건소장은 21시 37분언론보도를통해이미사고를인지한상태로상황을전파받았다 ). 경상북도보건정책과또한 21시 56분경주시보건소장에게상황을전파하였다 (Fig. 1). 경주시보건소의현장출동은현장지휘소의요청이나소방상황실의요청이아니라경주시보건소에서 21시 37분에사고상황인지와동시에결정하였다. DMAT의경우 22 시-22시 06분까지당시소방방재청 ( 현국민안전처 ) 구급과에서울산대학교병원, 안동병원응급실에 DMAT 가동을요청하였으나출동결정으로이어지지않았다. 이에 22시 08분에중앙응급의료센터에전화하여 DMAT 출동을요청하였다. 이에중앙응급의료센터에서는 22시 15분경보건복지부응급의료과로건의하여최종출동을결정하였다 (Fig. 2). 이에반해울산대학교병원은 22시에응급실당직전문의가중앙응급의료센터로부터사고상황을전파받자마자 DMAT 출동준비를시작하였다. 안동병원은 21시 30분에 TV를통해사고를인지하고 22시에상황을파악하면서부터바로 DMAT 출동준비를시작하였다. 22시 16분에보건복지부로부터, 출동을요청받아최종결정하였다. 경북대학교병원은 22시-22시 16분사이에보건복지부로부터 DMAT 출동요청을받고출동준비를시작하였다. 2. 현장재난의료활동현장재난의료활동은현장에도착한구급대원부터시작되었다. 경주소방서양남구급대가 21시 36분에최초로사고현장에도착하였고, 리조트입구의부상자응급처치및현장상황을전파하였다. 21시 43분지휘본부 ( 대응팀 ) 가현장에도착하였고, 대응팀중 2급응급구조사였던화재조사관이스스로탈출한경상자들을대상으로중증도분류를시행하였다 ( 중증도분류표는사용하지않았다 ). 119 구급차는그뒤로도계속현장에도착하여 22시 10분까지총 9 대의구급차가현장에도착하였다. 민간이송업구급차의경우울산지역구급차가가장먼저현장에도착하였으나정확한현장도착시간에대한기록은없다. 보건소장과경북지역응급의료지원센터직원은각각 22 시 10분경리조트입구에도착하였고, 22시 26분경재난현장인체육관앞에도착하여합류하게된다. 모여있던경상자들은보건소소속공중보건의가진료를시행하였고, 보건소장은지역응급의료지원센터직원과함께체육관에서들것으로구조되어오는환자 7-8명의중증도분류시행후인근병원으로분산이송을지시하였다 ( 중증도분류표는사용되지않았다 ). 현장처치가모두끝난경상자들은구급차로병원에이송되었다. Fig. 2에서볼수있듯이경주보건소장과정보센터직원도착전에이미 64명이상이
Mauna Ocean Resort Gymnasium Collapse / 101 Table 3. Incident response by timelines Time Rescue operation Time Disaster medical operation Feb 17 Gyeongbuk Regional Fire and Disaster Headquarter 21:06 situation room received the first report call 21:09 Collapse incident notification through broadcasting at the same time by all fire stations in the province, and standby of rescue teams and paramedics Feb 17 Situation propagation from Gyeongbuk Regional 21:10 Fire and Disaster Headquarter situation room to Gyeongbuk Emergency Medical Information Center 21:11- Dispatch request to Ulsan Regional Fire and Disaster 21:11- Dispatch request for hospital ambulance and Headquarter and National 119 Rescue Headquarter private ambulance services from Gyeongbuk Situation propagation to 25 institutions such as Regional Fire and Disaster Headquarter situation Gyeongju city hall, police agencies, and others Report room to the Ministry of Public Safety and Security 21:14 Report to the director of the Gyeongbuk Regional Fire and Disaster Headquarter 21:16 National Emergency Medical Center recognized the situation Gyeongbuk Regional Emergency Medical Information Center contacted the provincial government of Gyeongbuk 21:19 Report to the vice governor of Gyeongbuk province 21:29 Start of operation by the National Emergency Medical Center situation room 21:30 Report to the Ministry of Health and Welfare 21:32 Regional preliminary alert level 2 21:33 A staff member of the Gyeongbuk Emergency Medical Information Center was dispatched to the scene 21:36 First ambulance arrived at the scene 21:37 The head of Gyeongju Public Health Center learnt about the incident through media. Incident propagation from the mayor of Gyeongju city 21:38 The director of the Gyeongbuk Regional Fire and Disaster Headquarter took command of the situation room 21:40 First rescue team arrived at the scene 21:43 Emergency Response Team of Gyeongju fire station arrived at the scene, and took command 22:00 Ministry of Public Safety and Security requested 22:00 National Emergency Medical Center requested Ulsan University Hospital DMAT dispatch Emergency Medical Information Centers of Ulsan, Gyeongbuk, and Daegu for DMAT dispatch standby 22:06 Ministry of Public Safety and Security requested Andong Hospital for DMAT dispatch 22:08 Ministry of Public Safety and Security requested the National Emergency Medical Center for DMAT dispatch (Continued to the next page)
102 / 차명일외 Table 3. Incident response by timelines Time Rescue operation Time Disaster medical operation 22:30 Arrival of the director of the Gyeongju fire station, who took command 22:40 Emergency Rescue Control Headquarters of Gyeongju fire station arrived at the scene, and installed a field command post 23:20 Arrival of the director of the Gyeongbuk Regional Fire and Disaster Headquarter, who took command Feb 18 The director of the Gyeongbuk Regional Fire and 00:29 Disaster Headquarter presided the field command post interagency meeting 01:55 The final victim rescue completed 22:10 A staff member of the Gyeongbuk Emergency Medical Information Center arrived at the entrance of the resort Head of Gyeongju Public Health Center arrived at the entrance of the resort 22:15 Decision of DMAT dispatch from the Ministry of Health and Welfare 22:16 Ministry of Health and Welfare requested DMAT dispatch from Andong Hospital and Kyungpook National University Hospital 22:25 Advance team of Andong Hospital DMAT dispatch 22:26 Arrival of the staff of Gyeongbuk Emergency Medical Information Center and head of Gyeongju Public Health Center at the gym (disaster scene) 22:33 Disaster medical support-related Kakao Talk chat room opened 22:35 Advance team of Ulsan University Hospital DMAT dispatch Andong Hospital DMAT headquarters dispatch 23:00 Advance team of Ulsan University Hospital DMAT arrived at the scene Kyungpook National University Hospital DMAT dispatch 23:40 Advanced medical post installation completed Feb 18 00:20 DMATs treated 2 patients (1 dead after CPR) 01:00 Andong Hospital DMAT arrived at the scene Mayor of Gyeongju city requested DMAT dispatch from Dongguk University Gyeongju Hospital 01:05 Kyungpook National University Hospital DMAT arrived at the scene 01:17 Kyungpook National University Hospital DMAT returned 01:40 Andong Hospital DMAT joined the advanced medical post (Continued to the next page)
Mauna Ocean Resort Gymnasium Collapse / 103 Table 3. Incident response by timelines Time Rescue operation Time Disaster medical operation 06:05 Emergency duty released 02:05 One patient died after CPR 02:10 One male patient returned home after treatment 02:12 One female patient returned home after treatment 02:15 One female patient returned home after treatment 02:56 One male patient returned home after treatment 05:00 Dongguk University Gyeongju Hospital DMAT dispatch 06:00 Dongguk University Gyeongju Hospital DMAT arrived 07:20 Withdrawal command to advanced medical post 08:30 Withdrawal after cleaning up the site DMAT: disaster medical assistance team, CPR: cardiopulmonary resuscitation Fig. 1. The path of situation propagation and disaster medical assistance team dispatch. FDH: fire and disaster headquarter, EMIS: emergency medical information center, PHC: public health center, DMAT: disaster medical assistance team 송을시작하였고, 현장응급의료소설치완료이전에 86명이상이이송되었다. 응급의료지원센터직원은현장도착후부터현장응급의료소를설치할장소를선정하려고노력하였으나소방과협의중난항을겪었고, 결국울산대학교병원 DMAT 선발대가현장도착후 23시 00분이되어서야 DMAT이소방과협의없이정한장소에현장응급의료소를설치하기시작하여 23시 40분에설치가완료되었다 (Table 3). 현장응급의료소에서응급처치를시행한환자는총 7명이며이중2 명은심폐소생술후사망선언하였고, 1명은중증외상, 4 명은경증환자였다. 중증도분류표는사용되지않았고, 이 7명의환자에대한처치기록은남아있지않다. 경북대학교병원 DMAT은 01시 05분에리조트입구에도착하였으나, 악천후와도로사정으로 01시 17분철수를결정하였다. 안동병원 DMAT은 01시 40분에현장에도착하여현장응급의료소에합류하였다. 동국대학교경주병원 DMAT은경주시장으로부터 2월 18일 01시경에출동을요청받았으나출동할수있는차량이없어경주시에서차
104 / 차명일외 량을마련하여 05시에출동하였다. 동국대학교경주병원의출동은현장에있던경주시보건소장도인지하지못했고, 중앙응급의료센터상황실에서도인지하지못했다. 현장에서도다른 DMAT과의공조는없었다. 현장응급의료소는 07시 20분경상북도에서철수명령을받고 08시 30분에철수완료하였다. 현장에는총 4개 DMAT 39명이출동하였다. 현장응급의료소의지휘체계에대해살펴보면, 현장응급 Fig. 2. Patient transport status as per timelines. Fig. 3. Location of the hospitals that received the accident victims.
Mauna Ocean Resort Gymnasium Collapse / 105 의료소장은경주시보건소장이었고, 진료는울산대학교병원 DMAT에서주도하였다. 현장상황의보고는경주시보건소장을통한유선보고가있었고, 카카오톡을통한실시간보고도있었다. 카카오톡메신저는이전의다수사상자발생사고에서는쓰인적이없고이번사고에서처음사용되었는데, 중앙센터상황실에서주도하였다. 메신저에는보건복지부, 상황실, 지역응급의료지원센터, 현장의보건소와 DMAT 등이참여하였고, 소방에서는소방방재청이합류하여병원별환자방문현황, 현장응급의료소의환자진료현황등이모두공유되었다. 재난시공식적으로사용하도록규정되어있던통신수단인 trunked radio system 의경우현장으로이동중에는사용하였으나현장에서는통신이되지않아전혀사용되지않았다. 환자이송병원선정의경우중환자수용병원에대한지침은보건당국에의해결정되어현장에전달되었고, 경증환자에대한분산이송계획은없었다. 의료진에의해중증도분류가시행한일부환자의이송병원만의료진이선정하였고, 나머지환자는민간이송업, 병원구급차, 구급대원이각자선정하였다. 전체환자의 56.8% (88/155) 가현장에서가장가까웠던 2개병원으로이송되었으며, 119 구급차와민간이송업구급차로환자가이송된비율이 A병원의경우 51.1% (23/45) 대 31.1% (14/45), B병원이 53.5% (23/43) 대 44.2% (19/43) 로 119 구급차가환자의편중이송에좀더기여한것으로나타났다 (Fig. 3). 3. 병원내환자처치 DMAT을운용하는대형병원들과권역외상센터가사고소식을늦게전파받은것에비해울산, 경주지역의중소형병원들은대부분사고발생 30분전후로소방으로부터병원에서운용중인구급차를현장으로보내달라는요청을통해사고소식을전파받았다 (Fig. 1). 환자가집중되었던울산지역 2개병원의경우처음사고소식을전파받은시간과환자가의료기관에방문한시간사이에 1시간이상의시간이있어예비인력의소집과진료공간확보등의준비가가능하였고, 마침간호사교대시간이어서간호인력증원이용이했다고대답하였다. 경주지역병원들도 2시간정도준비시간을가질수있었다고대답하였다. 환자를진료한의료기관을종류별로살펴보면, 12개의료기관중권역응급의료센터는 1개소, 지역응급의료센터는 3개소, 지역응급의료기관은 4개, 응급실신고기관은 4개소였다. 의료기관중 1개소는리조트인근지역이아닌 60.1 km가떨어진곳에위치했는데, 이는환자들의주거지와가깝게위치했기때문이다. 응급의료기관의위치는 Fig. 3과같으며, 내원환자수는 Table 4와같다. 155명의환자중귀가한사람은 108명, 입원한사람은 11명, 전원한사람은 18명이었다. 평균응급실재원시간은 2.4±2.6 Table 4. Patient admission details from emergency medical institutes Emergency medical Hospitals Distance No. patients ER treatment results institute classification (km) (%) Discharge Transfer Hospitalization Death Unidentified Regional emergency medical center Hospital E 28.5 2 (1.3) 000 00 01 01 0 Local emergency medical center Hospital F 37.0 16 (10.3) 010 00 05 01 0 Hospital C 19.5 6 (3.9) 006 00 00 00 0 Hospital J 60.1 16 (10.3) 011 00 05 00 0 Local emergency medical facilities Hospital L 38.5 1 (0.7) 000 00 00 00 1 Hospital D 21.4 4 (2.6) 004 00 00 00 0 Hospital M 19.2 1 (0.7) 000 00 00 00 1 Hospital B 13.7 43 (27.7) 038 05 00 00 0 ER registered institutions Hospital G 35.1 8 (5.2) 007 01 00 00 0 Hospital H 34.5 7 (4.5) 000 07 00 00 0 Hospital I 34.7 6 (3.9) 000 05 00 01 0 Hospital A 08.3 45 (29.0) 032 00 00 07 6 Total 155 (100)0. 108 18 11 10 8 The distance is calculated by the distance traveled by car, and not the straight-line distance. ER: emergency room
106 / 차명일외 시간 ( 평균값 ± 표준편차 ) 이었다. 환자의주요수상부위는머리 (28.4%), 하지 (27.1%), 등 (21.9%), 상지 (13.5%), 가슴 (10.3%), 목 (9.0%), 기타 (11.0%) 순이었다. 수상부위가 2군데이상인경우중복으로집계하였다. 내원당일환자에게시행한검사는 X-선검사 (72.9%), 전산화단층촬영 (18.1%), 심전도 (7.1%), 혈액검사 (1.9%), 기타 (0.6%) 순으로보였다. 2가지이상검사를시행받은경우중복으로집계하였다. 환자에게시행한처치는대체로통증조절과외상처치였다. 진통제투여가 54.2% 로가장많았고, 창상처치와고정같은외상처치가 27.7% 를차지하였다. 2가지이상처치를받은경우중복으로집계하였다. 155명의환자중수술을시행한환자는총 3명으로, 한명은국소마취로건, 인대피하단열수술을받았고한명은중증외상으로 damage control 수술을받았다. 나머지 1명은 osteoplastic craniotomy and cranioplasty 수술을시행받았다. 환자의중증도는진단코드 ICD-10 기반으로한 EMR ISS로산출해보았다. 그결과응급실방문했던환자 155 명의응급실방문당시의평균 EMR ISS는 8.3±7.4점 ( 평균값 ± 표준편차 ) 이고 8점이하가 56명 (46.7%), 9-15점이 52명 (43.3%), 16-25점이 11명 (9.2%) 였고, 26점이상은 1명이었다. EMR ISS가가장높은환자는권역외상센터로이송된환자로 EMR ISS 65점이었고, ISS는 41 점이었다. 사망자에대한조사또한시행하였으나, 사망자 10명에대해부검이이루어지지않아정확한사인에대해서는조사가이루어지지않았다. 또한사망자들의현장구조시각에대한자료또한존재하지않아예방가능한사망의존재여부를판단하는데필요한정보는거의없는상황이다. 사망자의진단명은 Table 5에보인바와같다. 고찰이번사고는최소 155명의사상자를낸다수사상자발생사고로, 현장중증도분류와분산이송이제대로시행되지않았다. 이미이전의여러다수사상자발생사고에서도지적되었던부분이나, 놀랍도록전혀개선되지않은부분이기도하다 3,5,8). Table 4에서볼수있듯이재난현장에서가장가까운 2개병원에전체환자의 56.7% 가방문하였고, 또한보건복지부의질관리를받지않는응급실신고기관에전체환자의 42.6% 가이송되었고, 환자진료에필요한자원을갖춘응급실은진료능력을발휘하지못하였다. 155명중수술을시행한환자 3명중가장중증환자였던 1명은권역외상센터로바로이송되었으나, 이는소방이아니라 DMAT 의판단이었기에가능하였다. 2명은처음방문한응급실신고기관에서진단이잘못되어다른지역의권역외상센터에전원가서야제대로된진단과수술을시행받았다. 분산이송의가장큰걸림돌은현장지휘소가환자이송지휘를제대로시행하지않았던점에있었다. 각구급차는상황실이나현장지휘소에서이송전에정보를받지못해전체적인이송현황을모르는상태에서대부분가장가까운병원으로이송병원을선정했고이는다른다수사상자발생사고에서도마찬가지였다 8). 이에대한정부기관의개선방향을보면, 소방의경우사고발생초기 DMAT 이현장에도착하기전까지현장지휘소에중증도분류와분산이송을지휘할응급의료담당인력을증원하는방안을제시하였고, 소방과보건복지부모두보건소나 DMAT 이이역할을현장에서소방과협조하에신속하게시작할수있도록하는방안을제시하였다 14,15). 신속한 DMAT 출동을위해 DMAT 수를늘리고 DMAT 출동병원을더많이선정하여현장까지의소요시간을줄이겠다는방안이포함되어있다 14). 저자들은이에더하여몇가지개선방안을다음과같이 Table 5. Diagnoses of deceased victims Number Hospital Diagnosis 01 Hospital A Lung contusion 02 Hospital A Skull deformity, chest contusion 03 Hospital A Multiple fractures of the ribs, hemothorax 04 Hospital A Multiple fractures of the ribs, hemothorax 05 Hospital A Multiple fractures of the ribs, hemothorax 06 Hospital I No data 07 Hospital E Traumatic asphyxia 08 Hospital F Death on arrival (described in the medical record as head injury, right sided chest bruising, left sided lower chest bruising) 09 Hospital A First and second lumbar fracture, dislocation 10 Hospital A Unknown, right lung congestion
Mauna Ocean Resort Gymnasium Collapse / 107 제시하는바이다. 첫째, 소방의구급대원의재난의료대응역량을향상시킬수있도록중증도분류교육을강화할필요가있다 16,17). 둘째, 신속한 DMAT의현장출동과역량강화를위해병원기반의구급차출동시스템의도입을제시하는바이다 18). 본사고에서지적할또하나의큰문제는현장에서소방과의료진간협조체계가원활하지않았다는것이다. 특히소방과현장응급의료소설치장소문제로마찰이있었던사례는이전에도있었고, 이번사고에서도똑같이재현되었다. 현장응급의료소는현장재난대응체계의주요요소로법률에도현장지휘소가설치하도록기재되어있음에도, 여러다수사상자발생사고에서계속무시되어왔다 3,7,19). 이에대해보건소, 병원과소방서의합동훈련을더욱자주시행하는방안이제시되었다 15). 저자들은이에더하여각지역별로소방서-보건소-병원이재난의료협의체를구성하여자주만나면서지역내에서발생가능한재난에대해함께고민하며훈련을함께시행할것을제시하는바이다. DMAT 의출동이늦은것은이전의재난에서도반복된또하나의문제이다 5-8). 단, 이전의경우소방으로부터의상황전파가늦거나하는이유가있었으나, 본사고의경우에는 DMAT 출동결정이늦어 69분이나소요되었다. 이에대한개선방안으로보건복지부는중앙응급의료센터에 24 시간운영되는재난응급의료상황실 (Disaster Medical Control Center) 을설치하여기존에보건복지부공무원이가지고있던 DMAT 출동결정권한을상황실로위임하여, 상황전파와출동결정을신속하게하도록하였다 14). 이번사고에서주목해야할사항이하나있다면바로새로운통신수단으로모바일채팅메신저를사용했다는점이다. 이전의연구들에서재난시페이스북, 트위터와같이다양한종류의소셜미디어를사용하여재난대비, 대응, 복구단계에서지역사회와정부, 구조자등이정보를공유한사례가보고된바있고재난상황을위한모바일소셜네트워크플랫폼의개발노력도보고된바있다 20,21). 그러나실제재난에서재난대응인력사이에기존의무선통신의사용을완전히모바일채팅메신저로대치해서사용한사례에대한보고는없다. 이메신저의사용은음성전달에비해문자사용으로정보전송에필요한시간은다소길어졌다는단점이있었지만, 사진, 동영상등시각적정보의정보공유가빠르고정보가채팅창에계속존재함으로인해놓치는정보가적고, 당시주고받은정보가그대로보존되어사후검토에도사용되었다는장점이있었다. 이새로운통신수단은이후다른다수사상자발생사고에서도채택되어사용하기시작하였고, 중앙응급의료센터에재난응급의료상황실을설치된이후에는공식적인모바일상황실로사용되고있다. 단현메신저는상업적용도로개발되어있는것을그대로사용하고있어향후좀더해킹등보안문제가보완되고재난시필요한여러기능이추가된새 로운메신저의개발이필요한생태이다. 본연구의한계점은일개다수사상자발생사고의재난대응경험을바탕으로재난의료대응체계의문제점과개선방안을제시해보았다는것이다. 또한현장기록이많지않아정보수집에인터뷰에많이의존했는데, 인터뷰시점이사고발생 5개월이후부터진행되어기억에오류가있을수도있었다는점도한계점이되겠다. 결 2014년 2월 17일 21시 6분, 마우나오션리조트내체육관지붕이붕괴되는사고가발생하였다. 본연구결과사상자는총 155명으로집계되었고, 이중사망자는 10명이었다. 재난의료측면에서대응과정을관찰한결과, 사고인지는신속하였으나상황전파와 DMAT 출동결정은지연되었다. 현장에서의중증도분류와분산이송은제대로시행되지않았고, 소방과의료진간협조가원활하지않았으며, DMAT의활동은미미하였다. 특이한점으로는새로운통신수단으로모바일채팅메신저가재난대응인력사이에서사용되었다는점이다. 론 감사의말씀 본연구가진행될수있도록자료제공과인터뷰에응해주신모든기관관계자분들께감사드립니다. 특히본연구를적극지원해주신국민안전처, 경주소방서, 경주시보건소와, 어려운여건에서도흔쾌히의무기록제공을해주신 11개의료기관에깊은감사를드립니다. References 01. Shin JH, Kim JK, Yeom SL, Shin JH, Min SS, Lim YS, et al. Injuries and their complications after urban area fires: the dong-incheon live-hof restaurant fire. J Korean Soc Emerg Med. 2001;12:338-44. 02. Choi JT, Ahn ME, Ahn HC, Choi YM, Chung JB, Seo JY, et al. Analysis of victims of the fire that broke out at a beer bar in Inchon. J Korean Soc Emerg Med 2001;12:511-7. 03. Cho SJ, Yeom SR, Jeong JW. Suggestion for maintaining coordinated disaster response: review of disaster response to the air China aircraft crash near Kimhae airport. J Korean Soc Emerg Med 2003;14:9-16. 04. Chung JM, Seol DH, Park JB, Seo KS, Lee JH, Kim HD, et al. Analysis of transportation of victims of the subway fire in Daegu. J Korean Soc Emerg Med 2003;14:514-21.
108 / 차명일외 05. Kang S, Yun SH, Jung HM, Kim JH, Han SB, Kim JS, et al. An evaluation of the disaster medical system after an accident which occurred after a bus fell off the Incheon bridge. J Korean Soc Emerg Med 2013;24: 1-6. 06. Jang B, Cho J, Kim J, Lim YS, Lee G, Yang HJ, et al. Disaster medical responses to the shelling of Yeonpyeong Island. J Korean Soc Emerg Med 2013; 24:439-45. 07. Ko HJ, Lee KH, Kim OH, Cha YS, Cha KC, Kim H, et al. Experiences of a disaster medical assistant team in the Chun-cheon landslide disaster. J Korean Soc Emerg Med 2013;24:493-9. 08. Chae H, Kim GB, Park WN,, Park JS, Seo JS, Kim IB, et al. Experiences of disaster medical response system in a fire at Goyang bus terminal. J Korean Soc Emerg Med 2015;26:149-58. 09. Available from: http://www.munhwa.com/news/ view. html?no=2014 021901070527089002. Accessed July 24, 2015. 10. Available from: http://news.kbs.co.kr/news/view.do? ncd=2812197. Accessed April 15, 2016. 11. Gyeongju Fire Station. Report on emergency rescue activities: Mauna Ocean Resort gymnasium collapsing. Gyeongju: Gyeongju Fire Station; 2014. 12. National Emergency Medical Center. Report on disaster medical response of Gyeongju Mauna Ocean Resort gymnasium collapsing. Seoul: National Emergency Medical Center; 2014. 13. Kim J, Shin SD, Im TH, Lee KJ, Ko SB, Park JO, et al. Development and validation of the excess mortality ratioadjusted injury severity score using the international classification of diseases 10th edition. Acad Emerg Med 2009;16:454-64. 14. Ministry of Public Safety and Security. Plans for followup measures after Gyeongju Mauna Ocean Resort gymnasium collapsing: strengthening the emergency rescue capacity at disaster scene. Seoul: Ministry of Public Safety and Security; 2014. 15. Ministry of Health and Welfare. Emergency medical support guidelines for large-scale casualties occurring accidents. Sejong: Ministry of Health and Welfare; 2015. 16. Risavi BL, Salen PN, Heller MB, Arcona S. A two-hour intervention using START improves prehospital triage of mass casualty incidents. Prehosp Emerg Care 2001;5:197-9. 17. Deluhery MR, Lerner EB, Pirrallo RG, Schwartz RB. Paramedic accuracy using SALT triage after a brief initial training. Prehosp Emerg Care 2011;15:526-32. 18. Baker DJ, Telion C, Carli P. Multiple casualty incidents: the prehospital role of the anesthesiologist in Europe. Anesthesiol Clin 2007;25:179-88. 19. Law on Emergency Rescue Response Activities and Field Command, No. 1153 (April 3, 2015). 20. Houston JB, Hawthorne J, Perreault MF, Park EH, Hode MG, Halliwell MR, et al. Social media and disasters: a functional framework for social media use in disaster planning, response, and research. Disasters 2015;39: 1-22. 21. Hu X, Leung VCM, Du W, Seet BC, Nasiopoulos P. A service-oriented mobile social networking platform for disaster situations. In: IEEE Computer Society. 2013 46th Hawaii International Conference on System Sciences; 2013 Jan 7-10; Maui, HI, USA. Washington, DC: IEEE Computer Society; 2013. p.136-45.