A disaster is by definition a situation in which the resources available do not match the demands of the population impacted. This often forces serious modifications in standards of best practice, all coping activities, and expected outcomes. Generally in most disasters, if assistance from outside is unavailable, mortality rates and disabilities are much higher than during crises which are met with adequate resources. “Disaster medicine” is population based, which is vastly different to individual-based medicine. The goal of medical care applied during disasters is to provide the best for the many, to treat only those expected to survive with treatment, and to not waste scarce resources. This means reduced quality of health care, even with optimal use of all available resources. The term “health disaster” is also used as it indicates how a disaster deteriorates health indirectly through destruction of infrastructure and societal functions.

The term “disaster anesthesia” has not been systematically addressed in the anesthesia literature. In fact, a definition has not reached consensus within the community of anesthesiologists responding to disasters. Narrative presentations dominate, underlining the brutal meeting of high-tech users and a low-tech scenario. There are exceptions, but the bottom line is that this seems to have never been addressed in a conceptualized way. The first paper that surfaced is “The Anæsthetist in the Management of a Disaster” by Dobkin, Wyant, and Kilduff, dating back to 1957.¹ In a short editorial Hapuarachchi, in 2009, addressed “The Role of the Anaesthetist in Disaster Management,” pointing out the multi-faceted nature of disasters and the wide scope of challenges anesthetists may face.²

Also, since the job descriptions for anesthetists vary extensively throughout the world, universally accepted descriptions of anesthetists’ tasks and challenges will differ. Consequently, how anesthesia personnel from different “schools” handle and/or involve themselves in disasters will be different. What is applicable to certain European nations cannot automatically be applied to other countries, e.g. USA, India, and Japan. A book on disaster anesthesia must mirror the different scopes of the anesthesia specialty in different countries. In some countries anesthesia is confined to the operating theatre only, whereas in other countries the specialty of anesthesia includes pre-hospital care, intensive care, pain management, and emergency medicine, in addition to anesthesia in the operating room.

Disasters are a relative “thing.” Three critically wounded patients in a small district hospital will often qualify for the term disaster. The shoot-out at a political youth camp in Norway, July 22, 2011, killing 69 and wounding 66, could, however, be dealt with within an acceptable time frame and with no reduction in expected outcome. As such it was a tragedy of unprecedented proportion but did not qualify for the term “disaster,” after the killing had stopped. The situation will also vary according to where it takes place. An event in a rural district in a developing country may be very different from a situation taking place in an urban environment in an industrialized country. In this context, anesthesia has to find its place and be executed in a way that gives maximum outcome with the given resources, maintaining the best possible patient safety. More precisely, the anesthesiologist must optimize the use of his/her resources without reducing patient safety, compared to how they would have done it under normal circumstances, in spite of the increased numbers of patients needing to be treated.

In the little literature you find on this subject, disaster anesthesia is often seen as synonymous with anesthesia for mass trauma.³ This is, as we see it, too narrow minded. Disaster anesthesia encompasses more than just trauma anesthesia. In the majority of situations trauma will probably dominate as a challenge, both in sheer numbers but also with regard to type of trauma. Trauma patients from disasters may present themselves with a wider range of pathophysiology that goes beyond the traditional emergency trauma patient. The time factor is not on the patient’s side and the process of multiorgan failure may have started. For example, in cases of earthquakes (or otherwise collapsed buildings) delayed arrival at the hospital may give additional challenges as organ failure may already be present (e.g. renal failure due to crush syndrome and dehydration). In a mass shooting, hypotension due to blood loss is the dominating urgent problem, but the unpredictable internal ballistics will require extensive examination to identify all damaged organs and structures. In the absence of X-rays the slightest possibility of a pneumothorax will require a chest tube, prior to anesthesia, even without an X-ray and/or an ultrasound examination.

As such, disaster anesthesia comprises a mixture of many challenges, including mass casualties in civilian life (railroad accidents, fire accidents, naval tragedies), war surgery encompassing field anesthesia, including pre-hospital care (in many countries) and other non-surgical events. The Bhopal tragedy in India in 1984, with the release of methyl isocyanate, required ventilatory and medical support to an extent far beyond existing resources; a huge disaster without any need for surgery, but with permanent damage to health, even with optimal therapy.^{4, 5}

What contributes to these challenges may be listed, e.g. Box 1.1.

Figure 1.1 Children constitute a depressingly high proportion of patients. They are a vulnerable group and also present different challenges compared to adults.

These challenges require additional elaboration and consideration. Anesthesia is no longer just a choice of anesthetics and how to handle patients. It starts with strategic thinking, hopefully done beforehand. How do you plan for the above? Thereafter, what tactical modifications are needed to make the hospital master plan function?ⁱ How to organize your hospital and yourself to get maximum numbers of patients treated? How to optimize safety with as little reduction as possible in patient comfort? This differs from country to country. In some countries one can increase the working hours for each employee. This works in countries with less than 50 work hours a week; however, it is less applicable to countries where hospital workers (e.g. physicians) already have rosters of 80 working hours a week. The basic objective is optimal patient flow, and this again demands that some “sacred cows” may be sacrificed. Two operating tables per anesthesia machine is normally unheard of, but will help tremendously in increasing patient flow. If a hospital has floor-fixed sockets, this is difficult. If the operating tables are on wheels, this is possible and reduces time between patients significantly. Set up your operating room in such a way that one anesthesia machine can serve two operating tables. A physician or nurse skilled in anesthesia can make the necessary preparations for the next patient while maintaining anesthesia on the patient currently undergoing surgery, even if alone and without a mechanical ventilator. This may save up to 15 minutes between patients, without an increase in personnel. In a field hospital this is relatively easy to achieve. If your fixed installations are not originally designed for such flexibility, this may be more difficult. It is important to note that we have no indications that such an arrangement has jeopardized any patient’s safety. At the ICRC Hospital for War Wounded in Kabul, Afghanistan, 1991–1992, this was the standard setup. No unfortunate incidents were registered, in spite of a patient flow of 4000–6000 per year divided between an average of three surgeons, three anesthesiologists, and three expatriate operating theatre nursesⁱⁱ (Figure 1.2).

Figure 1.2 Operating room at the ICRC Hospital for War Wounded, Kabul, Afghanistan, 1992. Three operating tables served by one anesthesiologist (and one local staff technician before curfew). After curfew it was served by one expatriate anesthesiologist only. One anesthesia machine was placed between tables 1 and 2 and one oxygen bottle to which a self-expanding bag was attached was sited between tables 2 and 3. No ventilators were available. The maximum turnover (secondary surgery only) was 39 patients in 7–8 hours.

Anesthesia

For an anesthesiologist trained in modern medical centers, in high-income countries, responding to a disaster – at home or abroad – is not intuitive. Anesthesiologists must be trained to triage resources, to safely practice without best practice equipment and supplies, and to recognize futility for the sake of the many. Key words for disaster anesthesia are “safe” and “simple”. Disaster anesthesia is not a special form of anesthesia. It is the application of accumulated experience, using drugs and armamentarium in the most well-conceived, cost-effective, and time-efficient way, with the simple objective of helping as many as possible without reducing patient safety, but sometimes being forced to reduce patient comfort. A competent anesthesiologist capable of managing ruptured aortic aneurysms in elderly people with chronic obstructive lung disease and/or cardiac insufficiency should be more than capable of handling the different aspects of disaster anesthesia. The basic principles must always be adhered to. Also during disasters the three components, sleep, analgesia, and relaxation, will be the framework within which we operate (Figure 1.3). However, as the situation requires, one may be forced to sacrifice some procedures, either because they are resource consuming (equipment, consumables, or personnel) or time consuming. In a disaster setting, time is often your most precious “commodity.” Those procedures that add little to safety may be the first to be sacrificed/omitted. A typical example at the ICRC Hospital for War Wounded in Kabul, Afghanistan from 1990–1992 was not to empty the stomach before surgery (which was standard procedure in most hospitals at that time). We just decided that patients requiring intubation should be induced with rapid sequence intubation (RSI). Spontaneously breathing patients under ketamine anesthesia, on the other hand, were only observed carefully. Regurgitation or vomiting was never observed. NB: Bowel obstruction will always require gastric emptying.

Figure 1.3 The classic anesthesiological triangle. Some drugs have only one property (e.g. local anesthetics), some have two (e.g. ketamine), and some provide all three (volatile anesthetics).

Concomitantly, the provider of the analgesia/anesthesia must take into account other side effects which may be more relevant than in a controlled normal hospital situation. Planning for post-operative care starts in the operating room. If you have two nurses to take care of 20–30 post-operative patients, including patients in critical or serious condition waiting for surgery, and subject to surveillance and retriage, post-operative pain control cannot be as perfect as you want it. You have to keep a good distance from respiratory depression. During surgery, but even more so post-operatively, too much pain treatment may cause respiratory depression, and, if not recognized, be fatal for the patient. Insufficient pain treatment, on the other side, causes significant stress and may also hamper the patient’s situation and increase the risk of complications, both mentally and physically. The proper balance between patient safety and patient comfort is therefore an art in its own right (Figure 1.4).

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Chapter 4 – Total Intravenous Anesthesia in Disaster Medicine Chapter 6 – Airway Management Chapter 15 – Chemical and Radiologic Exposures in Trauma and Disasters Chapter 16 – Pain in Disasters Chapter 12 – High-Altitude Physiology and Anesthesia Chapter 21 – Operation Tomodachi: Anesthetic Implications

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