Lessons learned from home and abroad
Orthopaedic surgeons shared their first-hand experiences with disaster response, lessons learned, and suggestions for how to respond to future disasters during a symposium on disaster-relief orthopaedics at the recent National Orthopaedic Leadership Conference in Washington, D.C.
Andrew N. Pollak, MD, chair of orthopaedics for the University of Maryland School of Medicine, recounted the health system’s experiences in Haiti following the 2010 earthquake.
“The death toll from the earthquake was estimated at 250,000, and probably half of the deaths occurred on the day of the quake,” Dr. Pollak said. “The remaining deaths occurred in the subsequent days and weeks and were due, in part, to the inability to get adequate relief onto the island in a timely manner. The University of Maryland already had a presence in Haiti prior to the quake, which facilitated our ability to respond,” he said.
In the six months following the disaster, University of Maryland medical teams treated 29,833 patients and performed 961 operative procedures under challenging conditions and with limited resources at Saint Francois de Sales Hospital in Port-au-Prince.
“We had access to four operating rooms and another with lower sterility options. Although the anesthesia machine worked, we preferred to use regional anesthesia whenever possible. There was a functional C-arm and a portable X-ray machine that didn’t always work. Suction was intermittent, the rooms were hot, and the equipment was incomplete throughout,” Dr. Pollak said.
He shared the following lessons learned from the experience:
- Everything will be more than twice as difficult as you think it should be.
- Unless you have a massive team, partner with another organization.
- Develop an exit strategy. Waiting for the local environment to “regain” its ability to deliver medical care to the population may or may not be realistic.
- Be prepared for challenges related to security, infectious threats, and cultural differences.
All hands on deck
The EF5 tornado that bore down on Joplin, Mo., on a quiet Sunday evening in May 2011 left in its wake a trail of destruction more than 13 miles long. St. John’s Regional Medical Center, a 367-bed facility, sustained a direct hit. C. Craig Satterlee, MD, of DFP Orthopaedics in North Kansas City, Mo., said the facility lost power, and its generators and disaster medical supplies, which had been stored on the first floor, were destroyed. In addition, water, sprinkler, sewer, and gas lines were disrupted. As a result, all 183 patients and 117 staff had to be evacuated.
“St. John’s tornado disaster plan did not account for a direct hit, especially of that magnitude, but within 30 minutes, the facility’s emergency department director, quality director, and chief executive officer were on the scene; it was an all-hands-on-deck situation,” Dr. Satterlee said. Because the hospital had been evacuated, incoming patients were triaged in the parking lot and transported by ambulances, trucks, and handicap-equipped school buses to nearby Freeman Hospital West, which had sustained only minor damage. Inpatients were transported to more than 50 facilities across four states.
The hospital said prior disaster training and preexisting relationships helped the medical staff respond to the storm’s unexpected severity. “Even though the hospital had a disaster plan and was aided by the Missouri Emergency Response Commission and the Kansas City fire department, it was the relationships with hospital directors in nearby cities and local townspeople that kept things going,” Dr. Satterlee said.
St. John’s also recognized it needed to fortify the facility as it rebuilt—the storm moved the hospital off its foundation—and to bunker the intensive care unit (ICU), medical supplies, and generator. “When the tornado hit, most patients were relocated into interior hallways, but the ICU patients could not be moved. As a result, when the storm’s 200 mph winds broke the windows in the ICU, five patients who were on ventilators were killed,” Dr. Satterlee explained. Additionally, the hospital learned the importance of anticipating communication outages and having access to patient electronic medical records.
Prepare for all possibilities
“Disaster plans need to account for every single possible situation because you never know what is going to happen,” said Pablo V. Marrero, MD, the Board of Councilors’ representative from Puerto Rico, as he relayed the island’s experience with last year’s Hurricane Maria. The effects of the category 4 storm that made landfall on Sept. 20, 2017, he said, were devastating.
“The entire population was without electric power, running water, and fuel. For many, the outages lasted months. Eighty-five percent of the grid infrastructure was lost, and there was no cell phone, local television, or internet service. The airport was closed because there was no radar—no planes could make it onto the island for three days—and the ports were closed for three weeks,” he said.
Dr. Marrero pointed out that in addition to sustained winds, the storm produced extensive flooding and destroyed 60,000 homes; the refugee count was 20,000. Only eight of the island’s 68 hospitals were operational. For many months, citizens, including those with chronic illnesses, had no access to urgent medical care, medications, or life-sustaining equipment such as dialysis, oxygen, and ventilators. “Although the official death toll was 64 at three months after the storm, a Harvard mortality study, published in the New England Journal of Medicine, estimated that 4,645 people died during that time,” Dr. Marrero said.
He provided the following suggestions for AAOS member involvement in future disasters:
- Be prepared—have a disaster plan for every situation.
- Increase education related to disaster relief from an orthopaedic point of view.
- Create groups of disaster-relief volunteers at the state society and national levels.
- Coordinate with orthopaedic industry business partners to obtain relief-effort equipment for use by volunteer surgeons.
- If possible, create a field hospital—perhaps in alliance with U.S. Armed Forces—that can be transported as close as safely possible to ground zero.
- Get in touch with other AAOS members in a disaster area to help with their immediate needs.
Policy updates, efforts to increase awareness
Jordan Vivian, manager of the AAOS Office of Government Relations, provided updates regarding disaster-response policy at the state and federal levels. Federal legislation includes the Good Samaritan Health Professionals Act, which includes clear liability protections for licensed healthcare professionals who volunteer healthcare services to victims during a declared national disaster. The federal MISSION Zero Act awards grants to trauma centers to incorporate military providers and care teams into their facilities. State disaster-response laws include the Emergency System for Advance Registration of Volunteer Health Professionals (ESAR-VHP), the Emergency Management Assistance Compact, and the Uniform Emergency Volunteer Health Professionals Act.
Mr. Vivian also reviewed the three types of AAOS-registered disaster-relief responders: Trauma-trained Surge Responder, Acute-phase Responder, and Sustaining-phase Responder. He noted that to become a registered responder, AAOS members must complete the Society of Military Orthopaedic Surgeons–developed disaster-response course, which is cosponsored by AAOS, the Orthopaedic Trauma Association, and the Pediatric Orthopaedic Society of North America. Members who have completed the course and who are interested in becoming a registered responder should email email@example.com.
The symposium’s final speaker, Roman Hayda, MD, associate professor of orthopaedic surgery at Brown University and director of orthopaedic trauma at Rhode Island Hospital, noted that disasters can hit any community, although people often only remember the large ones or those that took place in their own communities. “For these reasons, all surgeons should have at least an awareness of disaster-management principles,” he said.
Ways to increase levels of disaster-response awareness among orthopaedic surgeons, according to Dr. Hayda, include adding the topic to residency program curricula, the Orthopaedic In-Training Examination, and/or the American Board of Orthopaedic Surgery examination. “Planning and rehearsal are also keys to successful response,” he said.
He recommended that surgeons volunteer on hospital disaster-response committees and register through ESAR-VHP to engage with regional disaster-response systems. He also pointed out the importance of integrating orthopaedic efforts with trauma and military systems. Finally, Dr. Hayda highlighted the need to test the nation’s current disaster-response systems; strengthen state systems; and assess and remove barriers to federal, regional, and local systems.
Maureen Leahy is assistant managing editor of AAOS Now. She can be reached at firstname.lastname@example.org.
- Kishore N, Marqués D, Mahmud A, et al: Mortality in Puerto Rico after Hurricane Maria. N Engl J Med. 2018;379:162-170.