Abstract
Natural disasters and armed conflict kill and maim. In the immediate, emergency phase, patients suffering from trauma receive the highest priority. It is only later that the public health effects of destroyed infrastructure, displacement of population, and disorganization of the health system come into play and take precedence.
Introduction
Natural disasters and armed conflict kill and maim. In the immediate, emergency phase, patients suffering from trauma receive the highest priority. It is only later that the public health effects of destroyed infrastructure, displacement of population, and disorganization of the health system come into play and take precedence. 1–4 However, one major difference between a natural disaster and armed conflict is that the former is a one-off event: most injuries take place at the time of the event, whereas during combat, the injured arrive day after day, every day, until fighting ceases. Thus, during armed conflict, trauma remains a high priority even while the larger public health effects take their toll.
Acute pathologies during a disaster or armed conflict do not take a holiday. Surgical, and obstetric, emergencies continue to occur in any population: appendicitis, cholecystitis, complications of childbearing. However, the extreme event often compromises the capacity of the health system; access to ordinary health care is then decreased.5 Some surgical pathologies, such as the complications of typhoid fever, can actually increase in those regions where the disease is endemic because of the destruction of basic sanitation infrastructure.
Most evident during major disasters, however, are the “new” circumstances under which trauma and emergency surgery must be undertaken. There are, of course, minor disasters where the hospital system continues to function as before and the extra patient burden is well accommodated. This is often not the case after a major event or in the case of armed conflict. In this chapter, we shall deal with how surgical care should be developed and performed after a major natural disaster or intense armed conflict.
These new circumstances are often described by many surgeons as “primitive” or “austere.” In many respects, however, they reflect the normal working conditions in a low-income country. Good, scientifically based surgery is performed every day around the world in simple or austere circumstances, without a disaster having taken place. Techniques are adapted and are appropriate to the working conditions. Poverty does not forcibly result in poor surgery. Working with limited yet appropriate resources is often the most challenging aspect of disaster or war surgery for inexperienced or expatriate surgical personnel.6
Epidemiology
Two-thirds, and even more, of injuries suffered after most natural disasters and armed conflicts involve the limbs.7,8 Although not usually life-threatening in modern surgery, in the disaster setting these injuries represent the major surgical and nursing burden and are often associated with various degrees of long-term disability. Infection, nonetheless, remains a major problem in these dirty and contaminated wounds: tetanus, gas gangrene, and invasive β-streptococcal sepsis.
Life-threatening injuries usually kill within minutes or hours and, unless extraction and evacuation are performed early, relatively few such patients reach hospital in time for surgery to be performed.i Even so, only well-functioning local hospitals can intervene in the management of these patients. Outside surgical teams deployed to the scene of a major disaster usually arrive too late to be of help with these patients.9 In contrast, during armed conflict, casualties may continue to arrive over long periods and a foreign surgical team often has to manage these patients.
Delay in evacuation of the wounded – whether due to a lack of pre-hospital services, destruction of the road infrastructure, or simply distance – is a commonplace event after a major disaster or during armed conflict. This obviously has many follow-on consequences for the types of wounds encountered and the requirements for resuscitation.10
Triage of Casualties
It is important for medical personnel to understand the difference between a multiple-casualty incident (where resources can ramp up to deal with the load in the normal manner: surge capacity) and mass casualties (where medical services are overwhelmed and must accept limitations of care) or what has been called a compensated or uncompensated event.11 In the latter, there exists a category of patients that are best left to die in peace and with dignity. Their management would consume an extraordinary amount of limited resources when faced with the total number of victims, and their survival, in a dependent state, no blessing for them, their families, or their societies.
The pre-hospital organization of triage is essential if the hospital is not to be overwhelmed with patients suffering from minor injuries that can be treated successfully by simple first aid measures. When deployed to the site of a natural disaster the first measure to undertake is the setting up of first aid posts to filter the patients and organize patient flow to the hospitals. For reasons of security, this is usually not the case in situations of armed conflict: pre-hospital care and evacuation become more problematic and take more time to set up. Ultimately, the efficiency of pre-hospital measures depends largely on the pre-existing capacity of the affected country’s system of first aid.
Hygiene
A natural disaster or armed conflict severely affects the environment. Infrastructure is devastated, water supplies contaminated or cut off, shelter destroyed (Figure 3.1). One of the consequences is a deterioration in the level of personal hygiene. Scarce water for drinking and cooking is too precious for bathing, and facilities for personal cleanliness are often no longer available. The scene of the event is also in ruins: dust and dirt from rubble after an earthquake or bombardment; mud from a tsunami that infiltrates everything.
A field hospital, or still-functioning structure, should try to organize a facility for showering patients on admission, except obviously for those in extremis. Whether this can be improvised or not, or if water supplies are inadequate, in the operating theatre and under anesthesia, a proper scrub of the relevant body part with soap, water, and a brush should be performed. Any excessive hair should be shaved, if necessary. If we have written about basic hygiene here, it is because many surgeons often forget or ignore the obvious: there is no use in putting povidone iodine on top of dirt; it is still dirt. A proper scrub of the body part to be operated on is essential.
Examination and Resuscitation
The initial examination and resuscitation of injured patients proceeds in parallel according to the C-ABCDE algorithm, although most of the injured seen in disasters or armed conflicts will have minor to moderate rather than severe injuries.12
Whether due to the large number of patients or constraints of infrastructure, the major clinical problem facing the surgeon will be a lack of diagnostic technologies. Whereas multislice CT scanners are considered essential for first-world management of trauma patients, in a disaster, even a working plain X-ray machine is a great plus! The staff of the emergency reception department must learn (or re-learn) the “eye-ear-nose and ten-finger whole body scan”: a proper and complete examination of the patient, from head-to-toe, based primarily on one’s clinical skills.
Hypothermia is an especially acute problem for victims trapped under the rubble of collapsed buildings. Pre-hospital intervention in this regard is essential and simply covering the patient with a recovered blanket or sheet is beneficial. It should be noted that a bleeding patient loses body heat even in a tropical climate and environmental measures in the hospital must be undertaken to prevent or correct the condition. Resuscitation rooms and operating theatres should be warmed to around 30°C for trauma patients where possible; an uncomfortable temperature for those unaccustomed.
Quite commonly after natural disasters or during armed conflicts and primarily due to delay in evacuation, many patients in hypovolemic shock have not suffered severe hemorrhage, but rather are dehydrated by the time they arrive at a hospital. Rehydration here equals resuscitation.
Classically, resuscitation is begun with a balanced crystalloid solution (Ringers lactate is preferred) and for a great many patients is adequate, particularly for late arriving patients where hemorrhage has been modest and self-limited. The use of crystalloids in severely injured patients with massive hemorrhage is no longer advised, however.13 Recent developments in damage control resuscitation for this subpopulation implies limited use of crystalloids and early administration of a balanced composition of blood products, which poses a dilemma in situations of limited blood for transfusion.
Blood Transfusion
The willingness of potential donors to give blood is a function of many social and cultural factors. In some societies it is not a problem at all and the only limiting factor is the setting up of the facilities for collection, screening, and cross-matching. In other societies, however, much discussion and “negotiation” with family and clan members may be required. After many major catastrophes blood is simply not available in the quantities that most doctors would use under normal circumstances. Under these conditions a massive transfusion protocol is irrelevant; a simple transfusion protocol defining the criteria for the administration of blood and the maximum quantity to be administered to an individual patient should be introduced after discussion with all the members of the hospital team.
In these extreme circumstances the resort to “traditional” transfusion practice is the norm: no blood components; whole fresh blood is given, usually with very positive results.14 It should also be mentioned here that this is standard practice in many low- and medium-income countries. The fractionization/fractionation of blood into components is an expensive procedure and is common only in countries with a certain degree of industrialization.
Autotransfusion – giving shed blood back to the patient – is a time-tested method, especially in situations of limited resources, especially in remote rural hospitals in low-income countries.15 The hospital should have a protocol for such an event and preparation of the required materials made. Autotransfusion is most often employed in a patient with massive hemothorax, a ruptured spleen, or an ectopic pregnancy.
Antibiotics
Tetanus is an ever-present danger with open and dirty wounds, and immunization coverage around the world is unequal and inconsistant. Knowledge of local vaccination practice and rates is important. A routine protocol of antitetanic serum and toxoid vaccination should be implemented.
For many minor injuries simple wound toilet and antibiotic coverage is sufficient. This is not a call for the misuse of antibiotics, rather a selection of patients to the extent possible based on the experience of the surgeon.16
For those patients undergoing surgery, antibiotics are preferably given pre-operatively, or at least intra-operatively, and before the application of any tourniquet.
It is a misuse to give a cocktail of antibiotics in the attempt to prevent all types of post-traumatic infection. Prophylaxis should be targeted: Clostridia and β-hemolytic streptococcus are most important in soft tissue wounds. The best antibiotics are thus penicillin or a first-generation cephalosporin. For injuries to the chest, abdomen, or brain, standard protocols involving penicillin, ampicillin, first-generation cephalosporin, gentamycin, metronidazole, and chloramphenicol exist (Table 3.1). These antibiotics are relatively inexpensive and widely available. Their use should not, however, take the place of proper technique and good surgery: the best antibiotic.
| Injury | Antibiotic | Remarks |
|---|---|---|
| Minor soft tissue wounds | Penicillin-V tablets 500 mg QID for five days | |
|
|
|
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|
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| Hemothorax | Ampicillin 1 g iv QID for 48 hours, followed by amoxicillin tablets 500 mg QID | Total 5 days |
| Penetrating cranio-cerebral wounds | Penicillin-G 5 MIU iv QID and chloramphenicol 1 g iv TID for at least 72 hours | Continue iv or orally according to patient’s condition for a total of 10 days |
| Brain abscess | Same regime as for cranio-cerebral wounds plus metronidazole 500 mg iv TID | |
| Penetrating eye injuries | Penicillin-G 5 MIU iv QID and chloramphenicol 1 g iv TID for 48 hours |
|
| Maxillo-facial wounds | Ampicillin 1 g iv QID and metronidazole 500 mg iv TID for 48 hours | Continue iv or orally according to patient’s condition for total of 5 days |
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| Continue for 3 days depending on drainage |
Anti-tetanus measures for all patients.
Penicillin-G may be replaced by ampicillin or a first-generation cephalosporin according to availability.
Allergy to β-lactam antibiotics: replace with known standards (erythromycin, clindamycin etc.)
Related posts:
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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