Introduction

A field hospital is usually deployed to areas severely affected by natural disasters, in which local health-care systems would usually exhaust their resources, and would greatly benefit from any outside assistance. Maxillofacial and otolaryngology surgeons and head-and-neck (H&N) surgeons play a vital role in such field medical units due to their expertise in caring for acute trauma-care patients and treating emergent life-threatening conditions (i.e., airway injuries and H&N infections). In addition, field hospitals that arrive far beyond the “golden hour” of trauma are expected to treat daily routine H&N diseases that may exacerbate following the disaster, rather than focus only on trauma-related injuries.

Organization

Transport payload planning dictates which personnel and equipment will be eventually loaded onboard. Since space is limited, the exact surgical equipment and quantities will be determined by the hospital’s general director, according to the expected burden of casualties and their nature[1]. Those unique logistic features are covered in other chapters. Consequently, the H&N surgeon should expect a suboptimal “surgical wish list” as the least important items, such as the otological microscope or endoscopic surgical set, are not likely to be available. The H&N surgeon should prioritize his or her designated surgical equipment in advance. Table 21.1 lists the recommended equipment for the H&N surgeon.

The main surgical focus and capabilities of the field hospital are procedures performed by general and orthopedic surgeons such as laparotomies and fracture fixations[2]. Therefore, the integration of other surgical disciplines is challenging in certain aspects. H&N surgeries are not routinely prioritized and assigned to specific time slots in the OR. Most of these surgeries can be regarded as nonurgent, semielective operations. In addition, these surgeries are time consuming, due to unique features of this body area, dealing with complex anatomy, aesthetic aspects, and the challenges of anesthesia.

Surgical personnel will be assigned to a general surgical department responsible for the surgical complex. Due to the limited number of surgical staff and the expected high volume of patients, H&N surgeons are expected to assist as scrubbed personnel in other surgeries while not operating. Hospitalized patients from all disciplines are admitted into mixed wards, which mandates meticulous follow-up by their surgeons.

If feasible, the location of the field hospital should be adjacent to a local hospital or clinic as it enables the use of local advanced resources if absent, or when the local resources are superior to the ones brought by the field hospital (e.g., a CT scanner for delineating maxillofacial or neck injuries, or an audiology clinic for assessment of hearing loss before treatment is planned).

Trauma

Facial injuries are incapacitating, and can cause major sequelae, including impaired perception, aesthetic disfigurement, and functional debilitation. Patients who require craniofacial surgery will usually need complex craniofacial reconstruction[3], which can pose a major challenge in a field hospital (Table 21.2).

In this setting, these operations are usually longer in their duration, compared to the regular hospital setting, due to several factors:

1. 
   

   1. Surgical staff: the staff is usually composed of a leading H&N surgeon, surgical assistants, and an OR nurse; the latter two often not acquainted with such surgeries.

   
   
2. 
   

   2. OR setting: the lack of specialized specific surgical instruments in the field hospital armamentarium may necessitate improvisation and adjustment of basic surgical instruments. When planned, and brought along, delicate surgical instruments such as suction tips, forceps, and sutures can be helpful in carrying out surgeries in the H&N region.

   
   
3. 
   

   3. Patient factors: since every natural disaster is unique and they occur in different geographic locations, the surgeon should be acquainted with prevalent conditions in the disaster area; for example, submucosal fibrosis in Southeast Asia can adversely affect wound healing.

The mandible and the orbit are the most commonly involved in natural-disaster H&N trauma[4]. Hence, securing an airway tract and treating orbital injuries are the most important issues to be addressed, along with treatment and care of other facial skeleton fractures and soft-tissue injuries. The surgeon should opt for an immediate, definitive surgical correction of these fractures. Delayed reconstruction requires advanced equipment, augments the complexity of the operation, and usually will not be feasible in this type of setting.

The recommended treatment sequence must adhere to the advanced trauma life support (ATLS) protocol: gain control of the airway, gain control of any bleeding source, establish the state of consciousness, diagnose and treat any concomitant brain injuries, and carry out facial reconstruction.

Craniofacial reconstruction surgery requires establishing a wide surgical field, which enables exact visualization and exploration of fractures, precise fracture reduction, placement of internal rigid fixators, use of bone autografts, and treatment of soft-tissue injuries. Achieving the best aesthetic and functional results greatly depends on the use of internal rigid fixation materials and the use of bone autografts. However, the surgeon should balance aesthetic requirements against subjecting the patient to a double-site operation in such a suboptimal setting.

The surgical treatment must reconstruct the three-dimensional structure of the face – height or verticality, width and depth – restoring the aesthetic and functional pre-trauma status. This constitutes considerable challenges for the reconstructive surgeon in both planning treatment and surgical techniques. Usually panfacial fractures constitute a challenge for the reconstructive surgeon who not only should act as a surgeon but also as a leader of an interdisciplinary team composed of intensivists, neurosurgeons, ophthalmic surgeons, prosthetic dentists, and others. In the field-hospital setting, some of the abovementioned professionals will probably be absent, and the surgeon should conduct the surgery in a manner that will enable staged functional reconstruction later[5].

An important issue is the perioperative antibiotic coverage needed. In a regular hospital setting, H&N surgeries usually require coverage of Gram-positive cocci, such as Staphylococci and Streptococci. Yet, at a disaster scene, the pathogens may be different. For example, in an earthquake setting, the prevalent pathogens were reported to be Gram-negative Enterobacteria, originating from water and soil pollutions. Consulting with an infectious-disease specialist regarding the antibiotic coverage is recommended.

Pediatric patients will also present at the field hospital. The surgeon should always bear in mind the unique features of the pediatric population (e.g., greenstick fractures) and provide the best treatment (which can be nonsurgical), without compromising future growth and development of the facial skeleton. However, this more conservative treatment usually necessitates a prolonged follow-up period, which is not always feasible in these settings.

Delayed arrival of trauma patients to a properly equipped facility is characteristic of disaster scenarios. Unlike the usual medical route, where patients typically present minutes to hours after injury, in disaster situations, patients may arrive days afterwards; some partially treated and some not treated at all. Hence, the field hospital’s H&N surgeon may encounter pathologies rarely seen in a regular hospital. Examples from the field hospital in Haiti included various foreign bodies, including concrete and wall-plaster remnants within deep lacerated wounds, soft-tissue necrosis, osteomyelitis in the H&N region in young and otherwise healthy patients, and even deep wounds with secondary healing processes, which concealed proper anatomical view during reconstruction.