AAOS Now

Published 4/1/2011
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Mary Ann Porucznik

Disaster-relief orthopaedics

What you need to know before you go

In recent years, orthopaedic surgeons from around the world have been called upon to respond to catastrophic disasters. Whether a tsunami in southeast Asia, a flood in New Orleans, or an earthquake in Haiti, these disasters require massive relief efforts. Although news reports of the victims’ suffering may trigger an impulse among many orthopaedic surgeons to “drop everything and go help,” rushing off without appropriate preparation is unwise, said the panelists at the “Disaster-Relief Orthopaedics” symposium, held during the 2011 Annual Meeting.

According to moderator CDR Matthew T. Provencher, MD, MC, USN, education is the key to a successful humanitarian assistance/disaster relief effort. In Haiti, he noted, the USNS Comfort, a hospital ship, was deployed in a record 76 hours after activation, was accepting wounded civilians within a week, and, 5 days later, was “maxed out,” with every one of its 450 beds full.

“Often, volunteers don’t realize what an austere environment is like,” he said. “Issues such as electricity, water, sanitation, transportation, infrastructure, food, and communications—things that we don’t normally even think about—must be addressed.”

Recalling the devastation caused by Hurricane Katrina in 2005, Dr. Provencher noted that when winds damaged cell towers, and cell phone batteries wore out, communication became an issue. Ham radios, powered by generators, served as lifelines to those in need.

Be prepared
According to Roman A. Hayda, MD, volunteers should “be prepared for anything. Be flexible, be resourceful, and expect the unexpected.” But he also stressed the importance of triage, which, he said, enables relief workers to do the greatest good for the greatest number of people. Outlining the parallels between military echelons of service, he compared battlefield aid to on-site care and field hospitals to local clinics. But he also noted that disaster relief volunteers are frequently in an area of chaos.

“How you deal with that chaos is critical to the success of your mission,” he said. Advance preparations can help. “Get to know the area. Prepare yourself, mentally and physically. Be sure your team is prepared with supplies. Recognize that you will have limited resources, and know what you can do.”

Although traction has largely been replaced in the United States by the use of screws, nails, and pins to treat fractures, it is still a viable—and often the best—method of treating fractures in a disaster area. External fixation devices are also useful, said Dr. Hayda, because they are flexible and adaptable, can be used for immediate or definitive care, are minimally invasive, and can be applied without fluoroscopy or radiographs. Internal fixation is not only time-intensive, it may not be safe to perform in an austere environment.

When images are required, a hand-carried, mountable ultrasound may be better than an X-ray machine. “They are more portable and run longer on a single charge than any radiographic equipment,” Dr. Hayda noted.

The Internet and handheld devices are making it easier for volunteers to come prepared. Both the State Department and the Centers for Disease Control and Prevention have Web sites with information on conditions in disaster areas and on any necessary immunizations that relief workers may need to obtain before traveling. (See links in the online version of this article, available at www.aaosnow.org)

Knowing a little about the people, their customs, their language, and local standards is helpful. Volunteers who don’t speak the language should have a translator, even if it’s just a small electronic, handheld device.

Another issue that should not be overlooked is informed consent. Care discussions should involve the patient’s family, who will be providing most of the care after relief workers leave. And every patient should have a follow-up plan.

Stressing the fact that relief workers should first, do no harm, and second, “keep it simple and safe,” Dr. Hayda concluded, “We can all contribute, but go with a group. We don’t want any SUVs (spontaneous, unaffiliated volunteers)!”

Successful volunteers
According to CDR Trent Douglas, MD, FACS, MC, USN, Director for Surgical Services aboard the USNS Mercy, successful volunteers are ethical, flexible, credentialed, have reasonable expectations and a positive attitude, understand their scope of practice, and realize that the mission is not a vacation.

Volunteers should know the purpose of the mission (disaster relief versus humanitarian aid), partner with the right organization, satisfy all travel requirements in advance (passport/visa, immunizations, malaria prophylaxis), be safe, and bring their favorite small equipment, advised Dr. Douglas.

But he also noted that providing care in a catastrophic situation can seem inherently unfair because not everyone can be helped. Volunteers need to realize their personal limitations, as well as the limitations of the site and the mission. “Everyone has a role,” he said, “and as a team, we must utilize each individual’s strengths.”

He offered the following pearls:

  • Topical skin adhesive and absorbable sutures are your friends.
  • Leave the patients no worse off than the way you found them.
  • “No” is sometimes the best, safest, and kindest answer that you can provide.
  • Share your experiences with friends, colleagues, residents, and students.

Disclosure information: Drs. Douglas and Provencher—no conflicts; Dr. Hayda—AONA, BioIntraface.

The views represented are the personal observations of the presenters and do not necessarily reflect the views of the U.S. Navy, the U.S. Air Force, or the Department of Defense.

Mary Ann Porucznik is managing editor of AAOS Now. She can be reached at porucznik@aaos.org

Additional Resources:
State Department: International Travel

Center for Disease Control and Prevention: Traveler’s Health

Recent disasters: New Zealand, Japan
In February and March 2011, major earthquakes shook the western edge of the Pacific rim. On Feb. 22, a magnitude 6.3 earthquake shook Christchurch, New Zealand, resulting in hundreds of deaths and massive destruction. It was the country’s deadliest natural disaster in 80 years.

As this issue of AAOS Now went to press, the impact of the March 11 earthquake off the coast of Japan was still being measured. The 8.9 magnitude earthquake and subsequent massive tsunami killed thousands, damaged nuclear reactors, reshaped the country’s coastline, and shifted the earth’s axis.

In each case, the AAOS reached out, extending sympathy and pledges of assistance. Both New Zealand and Japan have active orthopaedic associations and strong ties to the Academy.

Writing to Gary John Hooper, MD, president of the New Zealand Orthopaedic Society, AAOS President Daniel J. Berry, MD, acknowledged the immense magnitude of the disaster. “Our hearts go out to you, your families, and colleagues. We are thinking of you in your time of national catastrophe.”

Similarly, in his letter to Kozo Nakamura, MD, president of the Japanese Orthopaedic Association, Dr. Berry extended “our utmost condolences and dismay at the destruction and loss of life you have suffered this day as a nation. … Should your orthopaedic community require additional aid and assistance, I hope that you will let us know. While we know you are well equipped to deal with such events, one of this magnitude is surely overwhelming. AAOS stands by you in your time of need and mourning.”

The AAOS is in contact with the International Medical Corps to provide volunteers and assistance if they are required. The AAOS international department and Disaster Preparedness Project Team have a process in place to respond should such a request be made.