Abstract
A disaster may occur through natural or man-made events. It can be the result of war, terrorist events, or through so-called acts of god such as floods, tsunamis, earthquakes, and droughts. The international anesthetist may be called upon to serve in these areas in surgical teams as part of a medical response, or may simply be passing through. Whilst the “disaster zone” will be inherently more dangerous than your operating theatre at home there are things you can do to mitigate the risk.
A disaster may occur through natural or man-made events. It can be the result of war, terrorist events, or through so-called acts of god such as floods, tsunamis, earthquakes, and droughts. The international anesthetist may be called upon to serve in these areas in surgical teams as part of a medical response, or may simply be passing through. Whilst the “disaster zone” will be inherently more dangerous than your operating theatre at home there are things you can do to mitigate the risk.
What is the Threat?
When responding to a disaster you now have the same risks as the population that you are there to help. In addition, whether a disaster is man-made or caused by nature, the population will now be struggling to survive and you may be seen as a way of improving their financial or ideological situation.
In 2012, 176 acts of violence were carried out against aid workers resulting in 274 aid workers being killed, kidnapped, or seriously wounded, and the rate of kidnapping of aid workers has been rising over the last 10 years.1 International medical workers are targeted more in kidnapping compared to local medical staff.
Risk to medical staff in disaster zones can be divided into non-violent and violent or criminal risks.
Non-Violent Risks
In the immediate aftermath of a natural disaster the population having survived the initial risk are now at risk from a further set of problems. Following an earthquake or flood, buildings will be damaged and therefore unsafe. They may collapse at any moment, or they may have dangers inside such as live electricity, jagged and rusty metal, or broken glass.
When setting up your treatment area, if you use existing buildings you should ensure that they are safe prior to allowing your team to enter. Many Non-Government Organisations (NGOs) have engineers, plumbers, or electricians attached to them performing other roles such as provision of clean water. These personnel will prove vital in the assessment of suitable accommodation and working areas for your medical team.
There may still be a requirement to enter unsafe areas to extract or treat casualties of the natural disaster. In these cases you should make a quick risk assessment of the situation before rushing in to help, as if you are injured there is now one more casualty and one less responder. Ensure you have adequate protective equipment. This equipment may be in short supply, and so it may be best to deploy with it. A non-exhaustive list includes:
1. Overalls or coveralls
2. Sturdy boots
3. Safety helmet
4. Thick gloves
5. Eye protection
6. Disposable treatment gloves
7. High visibility jacket.
Whilst it is tempting in a tropical area to wear flip-flops and board shorts, comfort from the heat may place you at risk from a preventable accident.
Infectious Diseases
The disaster will have disrupted local infrastructure such as sewerage, plumbing, and electricity. Much of the local population will have no shelter and there may be a large proportion of refugees. These factors all lead to an increase in the threat of infectious diseases such as malaria, dengue fever, and diarrheal disease. In order to provide the best care for the population you must ensure your and your team’s health. This is best done through preventive measures as follows.
Preventing Vector-Borne Diseases
1. Regular use of insect repellant (containing DEET)
2. Impregnating clothing with permethrin
3. Wearing long sleeves and pants at night
4. Sleeping under a mosquito net or dome
5. Removing potential mosquito breeding sites such as water buckets and coconut shells
6. Regular fogging and spraying of insecticide
7. Malarial preventative medication (doxycycline, mefloquine, or chloroquine in non-resistant areas).
Preventing Diarrheal Disease
1. Use of safe water for drinking, cooking, and brushing teeth
2. Washing hands regularly and after toileting (e.g. with personal alcohol-based cleaner)
3. Setting up a cleaning station for food utensils
4. Avoiding local food that is not piping hot
5. Proper siting of toilets.
Treatment of Drinking Water
Water may be treated by filtering, boiling, or by addition of chlorine or iodine. If planning for a group you should estimate the requirement of 10 liters of water per person per day.
There are many commercial filters available through camping stores. They are reasonably cheap and easy to use. Most will remove protozoa and bacteria, but often the size of the filter pores are such that they don’t filter out viruses such as hepatitis A. Such a filter will require the added use of chlorine- or iodine-based treatments. The filters will last longer if larger particles are removed first. This can be done by filtering through clean cloth or coffee filters.
Boiling will kill most protozoa, viruses, and bacteria. To be effective the treated water needs to be kept at 80° for greater than 60 seconds. The best way to ensure this is to bring the water to boil for 10 seconds prior to allowing it to slowly cool.
Chlorine treatments are available in tablet form, with each tablet normally treating one liter of water. The process takes 20 minutes to effectively treat all infective organisms in the water, however its effectiveness is reduced by the presence of semi-solids in the water. Cloudy water should be filtered before adding the chlorine. If treating large quantities pool chlorine or household bleach is as effective and may be more convenient. The bleach must be simple unscented bleach. Twenty liters of water requires half a teaspoon of granulated pool chlorine or 1 ml of 6% hypochlorite bleach. Two drops of iodine will treat one liter of drinking water. This is readily available to surgical teams in the form of betadine.
Road Traffic Accident
One of the biggest risk to travelers in the Third World is being involved in a road traffic accident (RTA). Many Third World cities have congested roads filled with unsafe vehicles. Road rules are often different to those in the travelers’ home countries and cars may be driven on the opposite side of the road too. Locals may use a different form of indication. In many nations rather than using an indicator, honking the horn signals an intention to do something. This can lead to an increased incidence of RTAs. On the upside most traffic is traveling at a reduced speed compared with First World nations, which may reduce the chances of being seriously injured if involved in an RTA.
Drivers should avoid distractions such as radios or talking on the phone, along with driving under the influence of drugs or alcohol. They should plan a route and study it prior to embarking on a road trip. As the risk from an impact is likely to be greater than the risk of entrapment, driver and passengers should wear seatbelts. The driver should avoid speeding and always allow a safe distance between their vehicle and the one in front. This will depend upon road conditions.
In RTAs, there may be an issue of compensation. If the medical aid worker is perceived as being wealthy it may lead to a situation where compensation is demanded. Local police may also see this as an opportunity to obtain money by way of a bribe through charging the aid worker with an offence. If it appears that the situation is starting to become dangerous for you after being involved in an RTA it may be prudent to move to a safe area such as your work place or a local embassy.
Vehicle Issues
You should ensure the vehicle is always fueled. It should be refilled when it gets to below half a tank to prevent running out in an emergency situation. A spare container of fuel is a good idea, but must be stored properly as petrol and diesel are dangerous goods. Fuel may be in short supply in a disaster and people may try to siphon fuel from your vehicle for use in their own vehicle or for use in a generator, for cooking etc. You can minimize the risk of this by ensuring the vehicle is parked in a secure area, and by using a locking fuel cap.
The vehicle should always be prepared for an emergency. There should be stores inside including drinking water, emergency food rations, first aid equipment, a torch, and communications equipment.
Vehicles should be parked in a well-lit area if possible and facing front out, this avoids reversing in an emergency. Before leaving a vehicle the driver should ensure that all windows are up, doors are locked, and there are no attractive items on display.
You should avoid posting stickers or signs on the vehicle that may upset or inflame situations. Whilst you may be proud of your nation there may be individuals in the country that you are in that have pre-conceived attitudes towards your country and its government. Medical stickers and signs may garner good will from some people; however, this must be balanced by the fact that certain criminal organizations may perceive that there are medical goods inside that will be of value to them on the black market.
Vehicles should be checked regularly to ensure they are road worthy. Daily checks should include:
Related posts:
Chapter 5 – Inhaled Anesthetics and Draw-Over Devices in Disaster Response
Chapter 4 – Total Intravenous Anesthesia in Disaster Medicine
Chapter 14 – Considerations When Working with Children and Families
Chapter 15 – Chemical and Radiologic Exposures in Trauma and Disasters
Chapter 12 – High-Altitude Physiology and Anesthesia
Chapter 21 – Operation Tomodachi: Anesthetic Implications
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