Re-establishing surgical care at Port-au-Prince General Hospital, Haiti

Surgical Procedures Performed by Emergency Medical Teams in Sudden-Onset Disasters: A Systematic Review

BACKGROUND

Emergency medical teams (EMTs) frequently provide surgical care after sudden-onset disasters (SODs) in low- and middle-income countries. The purpose of this review is to describe the types of surgical procedures performed by EMTs with general surgical capability in order to aid the recruitment and training of surgeons for these teams.

METHODS

A search of electronic databases (PubMed, MEDLINE, and EMBASE) was carried out to identify articles published between 1990 and 2018 that describe the type of surgical procedures performed by EMTs in the impact and post-impact phases of a SOD. Further relevant articles were obtained by hand searching reference lists.

RESULTS

A total of 16 articles met the inclusion criteria. Articles reporting on EMTs from a number of different countries and responding to a variety of SODs were included. There was a high prevalence of procedures for extremity soft tissue injuries (46.8%) and fractures (28.3%), although a number of abdominal and genitourinary/obstetric procedures were also reported.

CONCLUSIONS

Based upon this review, deployment of surgeons or teams with experience in the management of soft tissue wounds, orthopaedic trauma, abdominal surgery, and obstetrics is recommended.

Improving Management of Limb Injuries in Disasters and Conflicts

It has become clear that disaster relief needs to transition from good intentions or a charity-based approach to a professional, outcome-oriented response. The practice of medicine in disaster and conflict is a profession practiced in environments where lack of resources, chaos, and unpredictability are the norm rather than the exception. With this consideration in mind, the World Health Organization (WHO; Geneva, Switzerland) and its partners set out to improve the disaster response systems. The resulting Emergency Medical Team (EMT) classification system requires that teams planning on engaging in disaster response follow common standards for the delivery of care in resource-constraint environments. In order to clarify these standards, the WHO EMT Secretariat collaborated with the International Committee of the Red Cross (ICRC; Geneva, Switzerland) and leading experts from other stakeholder non-governmental organizations (NGOs) to produce a guide to the management of limb injuries in disaster and conflict.The resulting text is a free and open-access resource to provide guidance for national and international EMTs caring for patients in disasters and conflicts. The content is a result of expert consensus, literature review, and an iterative process designed to encourage debate and resolution of existing open questions within the field of disaster and conflict medical response.The end result of this process is a text providing guidance to providers seeking to deliver safe, effective care within the EMT framework that is now part of the EMT training and verification system and is being distributed to ICRC teams deploying to the field.This work seeks to encourage professionalization of the field of disaster and conflict response, and to contribute to the existing EMT framework, in order to provide for better care for future victims of disaster and conflict.Jensen G, Bar-On E, Wiedler JT, Hautz SC, Veen H, Kay AR, Norton I, Gosselin RA, von Schreeb J. Improving management of limb injuries in disasters and conflicts. Prehosp Disaster Med. 2019;34(3):330-334.

The changing health priorities of earthquake response and implications for preparedness: a scoping review

OBJECTIVES

Earthquakes have substantial impacts on mortality in low- and middle-income countries (LMIC). The academic evidence base to support Disaster Risk Reduction activities in LMIC settings is, however, limited. We sought to address this gap by identifying the health and healthcare impacts of earthquakes in LMICs and to identify the implications of these findings for future earthquake preparedness.

STUDY DESIGN

Scoping review.

METHODS

A scoping review was undertaken with systematic searches of indexed databases to identify relevant literature. Key study details, findings, recommendations or lessons learnt were extracted and analysed across individual earthquake events. Findings were categorised by time frame relative to earthquakes and linked to the disaster preparedness cycle, enabling a profile of health and healthcare impacts and implications for future preparedness to be established.

RESULTS

Health services need to prepare for changing health priorities with a shift from initial treatment of earthquake-related injuries to more general health needs occurring within the first few weeks. Preparedness is required to address mental health and rehabilitation needs in the medium to longer term. Inequalities of the impact of earthquakes on health were noted in particular for women, children, the elderly, disabled and rural communities. The need to maintain access to essential services such as reproductive health and preventative health services were identified. Key preparedness actions include identification of appropriate leaders, planning and training of staff. Testing of plans was advocated within the literature with evidence that this is possible in LMIC settings.

CONCLUSIONS

Whilst there are a range of health and healthcare impacts of earthquakes, common themes emerged in different settings and from different earthquake events. Preparedness of healthcare systems is essential and possible, in order to mitigate the adverse health impacts of earthquakes in LMIC settings. Preparedness is needed at the community, organisational and system levels.

The 2015 Nepal earthquake disaster: lessons learned one year on

INTRODUCTION

The 2015 earthquake in Nepal killed over 8000 people, injured more than 21,000 and displaced a further 2 million. One year later, a national workshop was organized with various Nepali stakeholders involved in the response to the earthquake. The workshop provided participants an opportunity to reflect on their experiences and sought to learn lessons from the disaster.

METHODS

One hundred and thirty-five participants took part and most had been directly involved in the earthquake response. They included representatives from the Ministry of Health, local and national government, the armed forces, non-governmental organizations, health practitioners, academics, and community representatives. Participants were divided into seven focus groups based around the following topics: water, sanitation and hygiene, hospital services, health and nutrition, education, shelter, policy and community. Facilitated group discussions were conducted in Nepalese and the key emerging themes are presented.

RESULTS

Participants described a range of issues encountered, some specific to their area of expertize but also more general issues. These included logistics and supply chain challenges, leadership and coordination difficulties, impacts of the media as well as cultural beliefs on population behaviour post-disaster. Lessons identified included the need for community involvement at all stages of disaster response and preparedness, as well as the development of local leadership capabilities and community resilience. A 'disconnect' between disaster management policy and responses was observed, which may result in ineffective, poorly planned disaster response.

CONCLUSION

Finding time and opportunity to reflect on and identify lessons from disaster response can be difficult but are fundamental to improving future disaster preparedness. The Nepal Earthquake National Workshop offered participants the space to do this. It garnered an overwhelming sense of wanting to do things better, of the need for a Nepal-centric approach and the need to learn the lessons of the past to improve disaster management for the future.

Surgical workload of a foreign medical team after Typhoon Haiyan

BACKGROUND

On 8 November 2013, Typhoon Haiyan struck the Philippines causing widespread loss of lives and infrastructures. At the request of the Government of the Philippines, the Australian Government deployed a surgical field hospital to the city of Tacloban for 4 weeks. This paper describes the establishment of the hospital, the surgical workload and handover to the local health system upon the end of deployment.

METHODS

A Microsoft excel database was utilized throughout the deployment, recording demographics, relationship to the typhoon and surgical procedure performed.

RESULTS

Over the 21 days of surgical activity, the Australian field hospital performed 222 operations upon 131 persons. A mean of 10.8 procedures were performed per day (range 3-20). The majority (70.2%) of procedures were soft tissue surgery. Diabetes was present in 22.9% and 67.9% were typhoon-related. The Australian Medical Assistance Team field hospital adhered to the World Health Organization guidelines for foreign medical teams, in ensuring informed consent, appropriate anaesthesia and surgery, and worked collaboratively with local surgeons, ensuring adequate documentation and clinical handover.

CONCLUSION

This paper describes the experience of a trained, equipped and collaborative surgical foreign medical team in Tacloban in the aftermath of Typhoon Haiyan. Sepsis from foot injuries in diabetic patients constituted an unexpected majority of the workload. New presentations of typhoon-related injuries were presented throughout the deployment.

The initial response to the Boston marathon bombing: lessons learned to prepare for the next disaster

OBJECTIVE

We discuss the strengths of the medical response to the Boston Marathon bombings that led to the excellent outcomes. Potential shortcomings were recognized, and lessons learned will provide a foundation for further improvements applicable to all institutions.

BACKGROUND

Multiple casualty incidents from natural or man-made incidents remain a constant global threat. Adequate preparation and the appropriate alignment of resources with immediate needs remain the key to optimal outcomes.

METHODS

A collaborative effort among Boston's trauma centers (2 level I adult, 3 combined level I adult/pediatric, 1 freestanding level I pediatric) examined the details and outcomes of the initial response. Each center entered its respective data into a central database (REDCap), and the data were analyzed to determine various prehospital and early in-hospital clinical and logistical parameters that collectively define the citywide medical response to the terrorist attack.

RESULTS

A total of 281 people were injured, and 127 patients received care at the participating trauma centers on that day. There were 3 (1%) immediate fatalities at the scene and no in-hospital mortality. A majority of the patients admitted (66.6%) suffered lower extremity soft tissue and bony injuries, and 31 had evidence for exsanguinating hemorrhage, with field tourniquets in place in 26 patients. Of the 75 patients admitted, 54 underwent urgent surgical intervention and 12 (22%) underwent amputation of a lower extremity.

CONCLUSIONS

Adequate preparation, rapid logistical response, short transport times, immediate access to operating rooms, methodical multidisciplinary care delivery, and good fortune contributed to excellent outcomes.

A Prospective Study of the Outcome of Patients with Limb Trauma following the Haitian Earthquake in 2010 at One- and Two- Year (The SuTra2 Study)

Background Severe limb trauma is common in earthquake survivors. Overall medium term outcomes and patient-perceived outcomes are poorly documented. Methods and Findings The prospective study SuTra2 assessed the functional and socio-economic status of a cohort of patients undergoing surgery for limb injury resulting in amputation (A) or limb preservation (LP) one year and two years after the 2010 Haiti earthquake. 305 patients [A: n=199 (65%), LP: n=106 (35%)] were evaluated. Their characteristics were: 57% female; mean age 31 years; 74% of principal injuries involved the lower limb; 46% of patients had an additional severe injury; 60% had fractures, of which two-thirds were compound or associated with severe soft tissue damage; 15% of amputations were traumatic. At 2 years, 51% of patients were satisfied with the functional outcome (A: 52%, LP: 49%, ns). Comparison with the 1-year status indicates a worsening of the perceived functional status, significantly more pronounced in amputees, and an increase in pain complaints, mainly in amputees (62% and 80% of pain in overall population at 1- and 2-year respectively). Twenty eight percent (28%) of LP and 66% of A considered themselves as “cured”. 100% of LP and 79% of A would have chosen a conservative approach if an amputation was medically avoidable. Two years after the earthquake, 23·5 % of patients were still living in a tent, 30% were working, and 25·5% needed ongoing surgical management. Conclusions Only half the patients with severe limb injuries, whether managed with amputation or limb preservation, deemed their functional status satisfactory at 2 years. The patients’ perspective, clearly favors limb conservative management whenever possible. Prolonged care and rehabilitation are needed to optimize the outcome for earthquake survivors with limb injuries. Humanitarian respondents to catastrophes have professional and ethical obligations to provide optimal immediate care and ensure scrupulous attention to long-term management. Keywords Haiti earthquake, limb injury, two-year outcome, patients’ perspective, amputation, limb salvage

A qualitative and quantitative study of the surgical and rehabilitation response to the earthquake in Haiti, January 2010

BACKGROUND

The disaster response environment in Haiti following the 2010 earthquake represented a complex healthcare challenge. This study was designed to identify challenges during the Haiti disaster response.

METHODS

Qualitative and quantitative study of injured patients carried out six months after the January 2010 earthquake in Haiti to review the surgical inputs of foreign medical teams.

RESULTS

Study findings revealed a need during the response for improved medical records and data gathering for regulation, quality assurance, coordination and resource allocation; wider adherence to standard patient referral mechanisms and protocols linking surgical service provision with appropriate hospital and community based rehabilitation services; a greater recognition of the impact of non-amputation injury, and the need for patients to have a greater say in their management and to be the keepers of their medical records. Key first steps to improving the international response are a minimum dataset and uniform reporting.

CONCLUSION

This study showed that challenges for emergency medical response during the Haiti Earthquake involved issues of accountability, professional ethics, standards-of-care, unmet needs, patient agency and expected outcomes for patients in such settings:

Integrating population health into a general surgical residency curriculum

The once disparate fields of public health and medicine are slowly converging and reintegrating. Public health principles of community interventions and partnerships to effect better population health are included in the curricula of more medical schools. For graduate medical education, the specialties of internal medicine, family medicine, and preventive medicine are intuitively obvious population health partners, whereas surgeons have been relatively silent in this area. Despite the fact that many common surgical diseases are directly attributable to preventable causes, including cancer, trauma, and obesity, surgical residents receive little formal population health education. However, surgeons have always been and are increasingly active within the public health sphere. Examples of surgical population health initiatives include trauma systems development and improvement, research on disparities, and global health initiatives, including disaster relief. This article describes a single institution experience utilizing modest curriculum changes, increased global health opportunities, and direct service learning to help integrate population health principles into a general surgical residency program.

Three phases of disaster relief in Haiti--pediatric surgical care on board the United States Naval Ship Comfort

BACKGROUND

On January 12, 2010, Haiti experienced the western hemisphere's worst-ever natural disaster. Within 24 hours, the United States Naval Ship Comfort received orders to respond, and a group of more than 500 physicians, nurses, and staff undertook the largest and most rapid triage and treatment since the inception of hospital ships.

METHODS

These data represent pediatric surgical patients treated aboard the United States Naval Ship Comfort between January 19 and February 27, 2010. Prospective databases managed by patient administration, radiology, blood bank, laboratory services, and surgical services were combined to create an overall patient care database that was retrospectively reviewed for this analysis.

RESULTS

Two hundred thirty-seven pediatric surgical patients were treated, representing 27% of the total patient population. These patients underwent a total of 213 operations composed of 243 unique procedures. Orthopedic procedures represented 71% of the total caseload. Patients returned to the operating room up to 11 times and required up to 28 days for completion of surgical management.

CONCLUSIONS

This represents the largest cohort of pediatric surgical patients in an earthquake response. Our analysis provides a model for anticipating surgical caseload, injury patterns, and duration of surgical course in preparing for future disaster response missions. Moreover, we propose a 3-phased response to disaster medicine that has not been previously described.

Principles and practice of disaster relief: lessons from Haiti

Disaster relief is an interdisciplinary field dealing with the organizational processes that help prepare for and carry out all emergency functions necessary to prevent, prepare for, respond to, and recover from emergencies and disasters caused by all hazards, whether natural, technological, or human-made. Although it is an important function of local and national governing in the developed countries, it is often wanting in resource-poor, developing countries where, increasingly, catastrophic disasters tend to occur and have the greatest adverse consequences. The devastating January 12, 2010, Haiti earthquake is a case study of the impact of an extreme cataclysm in one of the poorest and most unprepared settings imaginable. As such, it offers useful lessons that are applicable elsewhere in the developing world. Emergency preparedness includes 4 phases: mitigation or prevention, preparedness, response, and recovery. Periods of normalcy are the best times to develop disaster preparedness plans. In resource-poor countries, where dealing with the expenses of daily living is already a burden, such planning is often neglected; and, when disasters strike, it is often with great delay that the assistance from international community can be deployed. In this increasingly interconnected world, the Haiti earthquake and the important international response to it make a strong case for a more proactive intervention of the international community in all phases of emergency management in developing countries, including in mitigation and preparedness, and not just in response and recovery. Predisaster planning can maximize the results of the international assistance and decrease the human and material tolls of inevitable disasters. There should be a minimum standard of preparedness that every country has to maintain and the international assistance to achieve that. International academic medical centers interested in global health could strengthen their programs by prospectively including in them contingency planning for international relief operations. Healthcare professionals of these institutions who travel to disaster zones should rigorously prepare themselves and make provisions for collecting and reporting data, which will enrich the knowledge of this growing activity.

Surgery in global health delivery

Surgical conditions account for a significant portion of the global burden of disease and have a substantial impact on public health in low- and middle-income countries. This article reviews the significance of surgical conditions within the context of public health in these settings, and describes selected approaches to global surgery delivery in specific contexts. The discussion includes programs in global trauma care, surgical care in conflict and disaster, and anesthesia and perioperative care. Programs to develop surgical training in Botswana and pediatric surgery through international partnership are also described, with a final review of broader approaches to training for global surgical delivery. In each instance, innovative solutions, as well as lessons learned and reasons for program failure, are highlighted.

Quality of care in humanitarian surgery

Humanitarian surgical programs are set up de novo, within days or hours in emergency or disaster settings. In such circumstances, insuring quality of care is extremely challenging. Basic structural inputs such as a safe structure, electricity, clean water, a blood bank, sterilization equipment, a post-anesthesia recovery unit, appropriate medications should be established. Currently, no specific credentials are needed for surgeons to operate in a humanitarian setting; the training of more humanitarian surgeons is desperately needed. Standard perioperative protocols for the humanitarian setting after common procedures such as Cesarean section, burn care, open fractures, and amputations and antibiotic prophylaxis, and post-operative pain management must be developed. Outcome data, especially long-term outcomes, are difficult to collect as patients often do not return for follow-up and may be difficult to trace; standard databases for post-operative infections and mortality rates should be established. Checklists have recently received significant attention as an instrument to support the improvement of surgical quality; knowing which items are most applicable to humanitarian settings remains unknown. In conclusion, the quality of surgical services in humanitarian settings must be regulated. Many other core medical activities of humanitarian organizations such as therapeutic feeding, mass vaccination, and the treatment of infectious diseases, such as tuberculosis and human immunodeficiency virus, are subject to rigorous reporting of quality indicators. There is no reason why surgery should be exempted from quality oversight. The surgical humanitarian community should pull together before the next disaster strikes.

Comparing the cost-effectiveness of short orthopedic missions in elective and relief situations in developing countries

Background

The earthquake that occurred in Haiti on 12 January 2010 elicited an unprecedented response from the American orthopedic community. Many small organizations, such as Operation Rainbow, were thrust into the unfamiliar environment of relief surgery, whereas they normally provide short elective reconstruction missions in developing countries.

Materials

Because of the chaotic nature of relief work, it was assumed that the organization’s efforts would be less cost-effective than their usual elective work. To evaluate this conclusion, the present study was designed to compare the cost-effectiveness of the organization’s usual elective missions with the emergency relief provided in the wake of the Haiti earthquake.

Results and conclusions

The assumption that emergency costs would be higher was proven wrong, with estimates of $362 per disability-adjusted life-year (DALY) averted in the elective group, and $343 per DALY averted in the relief group.

Surgical relief work in Haiti: a practical resident learning experience

INTRODUCTION

A once-a-year, week-long surgical missionary trip to Haiti has become incorporated into our residency experience on a voluntary basis since 2007. The purpose of this article is to describe our experience with this mission effort during the last 4 years.

METHODS

Since 2007, at least one PGY 3-5 surgical resident from our program has traveled to the Hôpital Sacré Coeur in Milot, Haiti for a voluntary, week-long surgical mission working with the local health care providers. Their personal and clinical experiences in Haiti, in the surgical clinics, and in the operating room, were recorded.

RESULTS

Since 2007, 6 surgical residents and members of the surgical staff have traveled to Haiti for this surgical mission. During that time, a total of 247 patients were observed in the clinic and 184 surgical cases were performed. The case distribution covered a wide range of defined categories, including head and neck, breast, hernia, abdominal, biliary, stomach, small and large bowel, colorectal, skin and soft tissue, and urology. The personal aspect of this experience could not be quantitated but was profound.

CONCLUSIONS

We feel that the surgical missionary trip to Haiti is an asset to our program. It provides humanitarian surgical care to patients in need, teaching and infrastructure support to the local health care providers, a clinical and operative experience to our residents, and an invaluable personal experience.