After the bomb

their disaster strategies. But the massacre will leave its mark on all those involved. Thelma Agnew reports

Hugh Mills was on holiday in County Donegal when he turned on the television and heard that a huge bomb had torn apart the small market town of Omagh.

Tyrone County Hospital, less than a mile from the site of the explosion, is part of Sperrin Lakeland Health and Social Care trust, where he is chief executive. His staff were receiving most of the 220 casualties.

He arrived at the hospital less than four hours after the explosion. Staff, visibly distressed themselves, were dealing with the relatives of the injured and the missing, trying to answer their questions. Other than that, the scene was eerily calm.

'There were no patients in A&E. Our staff had dealt with all the casualties in terms of moving them to other departments, or to other hospitals.

'As I walked through A&E, I could see that what had taken place there was a tremendous test for everyone involved. Staff were coping.'

In operating theatres and on the wards of hospitals across Northern Ireland, a mammoth response to the disaster that took 28 lives - the biggest single atrocity in the history of the troubles - was under way.

The fact that the province's health services passed their greatest test yet is to the credit of all involved. But it is no surprise. Northern Ireland could give master classes in major incident management. All the managers and clinicians who spoke to HSJ about the Omagh bombing were veterans of previous terrorist atrocities.

Tyrone County Hospital rehearsed its major incident plan six weeks before the bomb. It held together under unimaginable pressures. Because the hospital is so close to the scene, the first casualties were arriving before staff knew what to expect.

The disaster plan was set in motion by the sister in charge of casualty and a call was put out, on local television and radio, for off-duty medical and nursing staff.

More than 100 nurses and doctors rushed to the hospital; one nurse drove from Dublin, and many offers of help were declined.

Not far behind were the trust's social services staff and community mental health nurses. When it comes to dealing with emotional fall-out, Northern Ireland's integrated health and social services system is 'a tremendous benefit', says Mr Mills.

Casualties were swiftly assessed in A&E and many were transferred, by road and air, to other major hospitals, including the Erne Hospital in Enniskillen, Altnagelvin Hospital in Londonderry, South Tyrone Hospital in Dungannon and the Royal Victoria Hospital in Belfast.

Mr Mills and other senior managers co-ordinated the hospitals' response, liaising with the ambulance service and police, and organising press conferences. Many of the managers have clinical backgrounds, so they also treated casualties. Administrative and clerical staff drew up lists of the dead and injured, and passed them to the incident centre at the town's leisure centre, where relatives were gathering.

Because they are part of Omagh's tight-knit community, trust staff did not have the option of keeping a professional distance from the horror. Several of their own relatives were among the injured.

Mr Mills recalls: 'A radiographer was on duty in our casualty department when her daughter was brought in with serious eye injuries and transferred to another hospital. The mother worked on, not knowing that her daughter was seriously injured.'

At Altnagelvin Hospital, 34 miles away, staff had 25 minutes to prepare before the first of 21 seriously injured patients arrived, nine of them by helicopter. As Northern Ireland's largest acute hospital outside Belfast, Altnagelvin has dealt with some of the worst terrorist atrocities of the past 30 years.

The major incident plan slid smoothly into place, eased by the fortunate coincidence that, thanks to a waiting list initiative, a full complement of surgeons and anaesthetists was already on site.

'Our hospital's response to the Omagh disaster was the most co-ordinated and well worked through that we could have had,' says Stella Burnside, chief executive of Altnagelvin Hospitals health and social services trust.

As at Tyrone County, emotional support systems were immediately set in motion. Altnagelvin was not deluged with relatives, so the focus from the start was on staff. Managers went from department to department, supporting staff

as they worked and checking

they had the resources they needed.

In the week after the bombing, all staff were debriefed and offered continuing counselling.

Trusts are also offering the support of outside agencies to staff at both hospitals - a particularly important option for senior

managers, says Rosie Murray of the Emergency Planning Society.

'Debriefing is there to allow an individual to talk about their feelings - it's not a procedural debriefing, it's an emotional debriefing. That is hard for managers to do in their own organisation.'

The Omagh massacre will leave its mark on all those involved. Even the satisfaction of a job well done is small consolation for staff.

Stella Burnside says: 'We have learned much over the years, and each time we do a formal review and put new measures in place. But no, you don't get used to it and you don't want to get used to it. There isn't anybody involved in this who won't be haunted by it.'

There are cautious hopes that the senselessness of the attack on Omagh will strengthen the peace process by uniting the country as never before against terrorists.

Paula Kilbride, chief executive of Eastern health and social services board, is confident that the new Northern Ireland assembly won't be distracted from normal business, including taking responsibility for the province's health services. 'People are more determined than ever to make a proper democratic process work in Northern Ireland.'

This tragedy stands out for the battle-scarred health service staff because it came at a time of supposed peace, because of the horrific nature of many of the injuries and because most casualties were women or children.

Paul Bateson, a vascular surgeon at Altnagelvin, thought of his own teenage daughter as he treated a young woman, one of many mutilated patients he saw that Saturday.

'This 20-year-old girl said: 'I have a lump in my neck and my foot is missing.' These patients were all fully conscious. I had to explain that we would have to do a lower leg amputation. To tell that to a 20-year- old... it's very hard. I have a habit of saying: 'Is that all right?' And when I said it, she looked me in the eye and said: 'No, it isn't.''