Scandinavian Journal of Surgery 94: 311318, 2005

NATURAL DISASTERS: THE SURGEONS ROLE

J. M. Ryan
The Leonard Centre of Conflict Recovery, Academic Division of Surgical Specialties, Royal Free and University College Medical School, London, UK and United Services University of the Health Sciences,Baltimore, MD, USA Key words: Natural disasters; trauma care; mass casualties

Arrive, work and leave in a spirit of humility Anon INTRODUCTION Between 500 and 700 natural disasters occur annually across the globe, affecting up to 150 million people. Earthquakes, storms and floods account for the majority but there are many other causative factors (Table 1). Such disasters result in a wide variety of adverse health outcomes, all of which will demand involvement by surgeons at some stage and to a varying degree. Public and environmental health agencies generally believe that surgical teams cannot arrive in time to influence outcome (1). However, although time is a key determinant of survival in natural disasters (Table 2), international surgical teams can play an important role in all phases of the medical response. In man-made mass casualty incidents, surgical assets are typically in place and the goals of the surgical response are well defined. In a natural disaster, surgical assets and resources must be brought in, and the goals of the surgical response depend on the time of intervention. The immediate goals (measured in days) of international surgical teams in natural disasters are to arrive as quickly as possible to support the local surgical effort, to increase local capacity and to add resilience to local medical assets which may have been severely degraded (2). As the disaster unfolds over time (measured in weeks to months), the
Correspondence: James M. Ryan, M.D. Leonard Cheshire Centre of Conflict Recovery 4 Taviton Street London WCIH OBT UK Email: james.ryan@ucl.ac.uk

TABLE 1 Natural disasters. Weather phenomena Tropical storms Floods Drought and famine Geophysical phenomena Earthquakes Land/mud slides Volcanoes Tsunamis

TABLE 2 Time of rescue and likelihood for earthquake survivors. Time before rescue (hours) <1 112 1224 2448 > 48 Total No. of survivors 1970 26 07 03 02 2350 Cumulative (%) 84 95 98 99 1000 0

From: Kaw LL: The July 1990 Earthquake in Baguio City. Dissertation for the Diploma of Medical Care of Catastrophes. The Society of Apothecaries of London: London, 2001

longer-term goals of the surgical response will shift to rehabilitation surgical services, provision of specialized surgical care (such as complex plastic and orthopaedic procedures), training, and long-term needs assessments. For example, the goals of this authors mission to the tsunami area in southeast Asia in December 2004 were: practical clinical support (if required), immediate needs assessment, provision of key medical equipment, training in the use of donated equipment and initial reporting on long-term needs (3).

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Thus the goals of an international surgical mission to a natural disaster area are typically more diffuse and difficult to define compared to a man-made mass casualty incident, and may even be open-ended. To achieve these goals, the response follows a distinct timeline comprised of two phases. In the first phase, rapid initial needs assessment is followed by deployment of a team (typically within days of the disaster). Later, a second phase assessment is undertaken (usually within weeks), to assess long-term needs. The aim of this article is to provide a brief overview of the principles and practical aspects of the surgical response to major natural disasters, from the perspective international surgical teams deployed to the disaster area. The literature is replete with evidence-based reports clearly showing how an effective intervention by international surgical teams can make a difference. Such specific examples are cited where appropriate. PLANNING AN EFFECTIVE RESPONSE About one billion people now live in unplanned shanty towns in some of the most disaster-prone regions on the planet. Matters are exacerbated by deforestation, environmental degradation and substandard living accommodation (1). Natural disasters are sudden onset events of large magnitude that usually occur in such disaster-prone geographic regions and involve large populations least able to cope. Planning for natural disasters is a combination of art and science. It requires understanding of global population dynamics as well as the particular circumstances surrounding such disasters. The United Nations has a specific body for this purpose, the United Nations Disaster Assessment and Coordination Agency (UNDAC). An UNDAC team (26 experts drawn from member countries) is quickly deployed to a disaster scene to assess and report on immediate needs (4). The team focuses on immediate threats to life (such as epidemics) and provision of water, food, shelter and sanitation, the four immediate determinants of survival (5). While UNDAC rarely employs surgeons in an initial assessment team, the team does assess surgical needs and reports to non-governmental organizations (NGOs) and other humanitarian aid organizations (such as the International Committee of the Red Cross or Doctors Without Borders) on the need for surgical input. Alternatively, there may be a direct request for surgical assistance from the health ministry of the affected country. For example, such a request from the Sri Lanka health ministry triggered a surgical/trauma assessment following the tsunami in December 2004 (3). Another example followed the Mount Pinatubo earthquake in the Philippines in June 1991, when the US Clark Air Force Base in Pampagna was asked for assistance (6). Planning an effective response relies on reliable pre-existing intelligence. For example, detailed epidemiology data for scores of disasters during the last decade are available in the situation reports found on the website of the UN Office for the Coordina-

tion of Humanitarian Affairs (OCHA) (7). At this stage it is also helpful to peruse Boyarsky and Shneidermans classic paper on natural and hybrid disasters (8), which provides a summary of the relative frequency of injury patterns commonly associated with natural disasters. This information allows not only risk analysis for future events but also a crude prediction of the nature and number of expected casualties, as demonstrated by the following recent examples. PATTERNS OF INJURY
EARTHQUAKES

Epidemiological data from multiple past earthquakes indicate that the number of people killed depends on the total number of collapsed structures and on the extent of the damage, numbers of occupants, time of day or night, the proportion of occupants trapped in the buildings, the proportion killed outright and the continuing mortality of trapped survivors. One obvious key to reducing mortality is timely extrication. From a surgical perspective, late preventable deaths occur due to prolonged entrapment causing crush syndrome and sepsis from neglected wound contamination or following inadequate surgery. Data from the Marmara (Turkey) earthquake in 1999 and the Bam (Iran) earthquake in 2003 vividly illustrate the magnitude of the surgical challenge (9, 10, 11). The Turkish earthquake resulted in > 17,000 dead and 43,000 injured. Among these 639 victims (12 % of all hospitalised) presented with renal failure, highlighting the need for specialised renal care including dialysis. There were 790 limb fractures, but much smaller numbers of patients with thoracic and abdominal trauma. The Bam earthquake resulted in 40,000 dead and 30,000 injured. Of these, some 12,000 injured were airlifted to regional care centres. The injury patterns from Bam mirror the findings in Turkey, except that renal failure rates were very low in the Bam report (2.9 %) and this was attributed to short time period under the rubble (TPR). In both reports TPR was highlighted as an important factor in determining the likelihood of nephrologic sequelae. However, there is disagreement concerning the relationship of acute renal failure to TPR.
STORMS, FLOODS AND TSUNAMIS

Following severe flooding or inundation of costal areas by seawater, drowning will cause the majority of deaths. Survivors present not only with water inhalation and near-drowning but also with complex limb fractures, soft tissue injury and penetrating trauma from broken glass, wood shards and other floating debris (Fig. 1). These soft tissue wounds are often heavily contaminated by filthy water and raw sewage. Specialised surgical expertise is therefore required to address delayed and contaminated wound management, and later complex limb reconstruction. Accurate data may be difficult to obtain in the aftermath of a natural disaster. The author, working

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with a needs assessment team, visited each receiving hospital in Sri Lanka soon after the tsunami of December 2004. While overall figures for the numbers of injured were available, hard data regarding patterns of injury were not, and individual surgeons interviewed gave wildly varying information (3). Table 3 gives the official data and shows the most marked feature of Tsunamis and storm surges the high ratio of dead to injured (approximately 2:1). The data from one of the worst affected hospitals, the University Teaching Hospital in Galle, was typical: within 2 hours of the tsunami 900 patients presented along with 1600 dead. One hundred of these 900 injured had soft tissue and orthopaedic injuries that warranted admission. As the hospital in Galle is a regional orthopaedic centre, there was sufficient capacity to cope during the acute phase without outside help. However, the hospital did request orthopaedic equipment and surgical skills training for the longer term. The situation in smaller district hospitals was quite different with single-handed general surgeons describing considerable difficulty in coping with large caseloads. However, at the time no international surgeons were on hand to assist (3). Two weeks later, they needed the help of international surgeons with complex reconstructions in about 10 cases with soft tissue loss and complex fractures requiring internal fixation. Reports from other areas affected by the tsunami support these observations (12, 13), including the high incidence of wound contamination with resistant bacteria (13). THE RAPID NEEDS ASSESSMENT The post-disaster needs assessment is vital to prevent the something must be done approach which leads to inappropriate and indiscriminate dispatching of surgical personnel and material. Surgical assistance must be targeted to those in need and should await the attainment of reliable information as to what is required. To achieve this, a rapid needs assessment must be carried out as soon as possible, while a more comprehensive second phase assessment concerned with longer term programme planning will follow later (4). The purpose of the rapid needs assessment (also termed initial assessment) is to determine immediate needs before anyone deploys and before any equipment is emplaned. This should occur as soon as possible (4, 5) and in consultation with local health officials. Individuals representing recognised international aid agencies will carry out this assessment (4), which typically dovetails with a more comprehensive assessment which includes water, food, sanitation, shelter and emergency medical needs. If trauma/surgical assistance is needed, a surgical team should be deployed to the area. The team must be field competent, self sufficient in food, water, medical supplies, transport and communication. Collaboration with local authorities and with other teams deployed by other agencies is of paramount importance to avoid duplication. The assessment visit typically begins by meeting senior health ministry offi-

Fig. 1. Tsunami victim with extensive soft tissue loss left thigh.

TABLE 3 Deaths and injuries caused by the tsunami in Sri Lanka on 26th Dec 2004. (Source Emergency Operations room of the Disaster Management Centre Colombo Jan 2005). District Affected Families 192 920 Number of persons Displaced Deaths 504 440 30 882 Injured 15 166 Missing 6 088

All

cials and an up-to-date briefing as the situation on the ground changes day by day in the immediate aftermath of a disaster. Key goals must be re-clarified with local officials. The authors recent experience in Sri Lanka after the tsunami (3) illustrates these critical points (3). The rapid assessment team was small but focused on a well-defined objective, with each member having a clear task. Fig. 2 shows the rapid assessment team consisting of paediatric and adult orthopaedic surgeons, a vascular surgeon, a general trauma surgeon and a psychiatrist, each specifically requested by the local health ministry in consultation with local surgeons. The team carried sufficient medical and trauma life support equipment for the team and small quantities of trauma and orthopaedic equipment specifically requested by local surgeons. The visit duration was 12 days a typical period if useful intelligence is to be gleaned. The report (available from the Leonard Cheshire Centre at http://www.ucl.ac.uk/ lc-ccr) outlines a typical profile of a rapid needs assessment mission. In establishing surgical priorities, the team must be aware of the Big Picture of the disaster relief efforts and overall health priorities as established by international aid agency personnel. Some form of documentation is needed. Widely used assessment forms (5) can be adapted to focus on surgical needs. The assessment team must gain a clear picture of the nature of the disaster, the immediate impact (including estimates of dead and injured and nature of injuries), the local medical response and an estimate of trapped or missing persons who may present in

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Fig. 2. Trauma assessment team in Sri Lanka, January 2005.

the coming days. Based on this, the team then develops an estimate of additional surgical assets (personnel and materiel) needed to mount an effective surgical response. MOUNTING THE SURGICAL RESPONSE The immediate surgical response is aimed toward acute trauma care of the injured, while a later response focuses on the rehabilitation of surgical services in the disaster zone. Based on the rapid needs assessment, the deploying agency plans the timing of deployment of teams, the mix of surgical skills within each team and the need for other skills or competencies (such as critical care, renal dialysis, obstetrics, pediatrics). Decisions are made regarding additional training required to develop a self-sustaining team able to operate in an austere environment, and on medical equipment and logistical support needed. Planning also involves acquiring intelligence on proposed work locations and developing a plan for power, water, sanitation and food supply for the team. Hawley (14), describing the UK military humanitarian intervention in Rwanda, and Bricknell and MacCormack (15) give detailed descriptions on the act of intervention and are essential reading.
TEAM COMPETENCIES AND PREPARATION

Most surgeons deploying from 1st world countries on a humanitarian mission to a natural disaster area will

have undergone specialty and subspecialty training. Few, if any, general surgeons remain in practice. This forces the mission planners to increase the size of the deployed surgical team, whether civilian or military, and has led to the expression surgeons hunting in teams (16). As an absolute minimum a team should consist of one torso surgeon and one orthopaedic surgeon, both with trauma experience. Additional skills (such as ATLS or DSTC/DSTS courses) are desirable (17). In austere environments teams have to care for themselves in a spirit of collaboration, team play and multi-tasking. Surgeons may have to turn their hands to driving, watch keeping, food preparation, and even manual labour. These constraints influence team member selection and require careful consideration. Key competencies for team members are listed in Table 4 (18). Preparation for deployment is critical, especially for those deploying for the first time, and should include both personal and professional aspects. High motivation and physical and mental fitness are of paramount importance. Many surgeons volunteering for such missions have previous experience working with aid agencies specialising in surgical care (e.g. the International Commission of the Red Cross or Doctors Without Borders). Others have military experience. Most reputable agencies will insist on some form of pre-deployment assessment, training and credentialing. When reinforcing a functioning local hospital, equipment needs (particularly for critical care, oper-

Natural disasters: the surgeons role TABLE 4 Competencies of team members.

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ATLS course Primary and secondary triage proficiency Multi-system trauma resuscitation Field craft Surgical approach to the trauma patient (DSTS/DSTC course) Critical care competency Command, organisation, transport skills and knowledge

ative, anaesthetic and postoperative care) may be modest. However, if existing hospitals have ceased to function, a full scale deployment of personnel and equipment will be required. Excellent and detailed advice on equipment scales can be found in the literature (19).
TRAUMA CARE IN THE DISASTER AREA

Fig. 3. Neglected and contaminated open fracture of leg treated with an Ilizarov frame.

An important early decision must be made concerning the limits of care. The question of whether care should be offered beyond trauma and extended to patients with disease or non-traumatic surgical conditions is always difficult. As a general rule, expatriate surgical teams deploying to a disaster region should limit early activities to trauma care, avoid raising expectations or creating a culture of dependency. Extending care beyond trauma may be considered later, when the implications of getting involved for the long term become clear. Care in the immediate phase involves mostly treating open, complex fractures with associated soft tissue injuries. Depending on time scale, many of the wounded will present with neglected, contaminated wounds complicated by local and systemic sepsis (Fig. 3). Many limbs will be beyond salvage, mandating immediate amputation. In others, traumatic amputation will have already occurred (Fig. 4). The guiding surgical principles are those espoused by generations of civilian and military trauma surgeons well versed in the surgery of open, contaminated wounds (20). The key principles are as follows: Preserve as much skin as possible use a scrubbing brush to remove in-driven debris. Perform fasciotomies along the entire length of the wound(s) and remember to open deep fascia planes. Repair arteries essential for limb survival, but do not repair nerves during the initial exploration. Instead, mark them for later reconstruction. Excise dead or heavily contaminated soft tissues and stabilise bone fractures using either external or internal fixation devices. Exposed joint cavities should be meticulously cleaned and covered. Otherwise leave wounds open. Finally, recognize irretrievably mangled limbs and amputate early. Crush syndrome poses a particular challenge in the austere setting. Reperfusion can lead to massive fluid sequestration (up to 10 liters per limb), precipitating hypovolemic shock. Myoglobinuria and hypovolemia lead to renal failure and need for dialysis for large groups of patients (9, 10, 11). As a rule, in the immediate aftermath it is best to avoid embarking on

Fig. 4. Traumatic amputation caused by tsunami.

multi-staged or complex reconstructions and instead focus on sound surgical care of wounds and fractures. THE SURGEONS ROLE IN THE AFTERMATH During the second phase of a natural disaster, much remains to be done and there is the danger that vis-

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Fig. 5. Neglected bi-lateral open Tibial fractures expertly managed with Ilizarov frames.

Fig. 6. US Army Medical Officer teaching post graduate medical students in northern Afghanistan.

Fig. 7. Expatriate and local surgeons operating together in Azerbaijan.

iting surgical teams will over-reach, attempt too much and fail. Careful planning and consideration of the surgeons role during the second phase is therefore of critical importance.

The initial surgical team may need to be augmented. If a decision is made to widen the scope of the mission to encompass vulnerable groups with medical and non-trauma pathology, consider the need for obstetricians and paediatricians with their own specific equipment requirements. The obvious risk is to offer aid beyond the skill range of the surgical team. Good advice is to stay in your lane. It is during the second stage that the need arises to undertake lengthy, costly and technically demanding limb reconstruction procedures involving orthopaedic and plastic surgeons. Such reconstructive work often hinges on specialized equipment (such as an operating microscope) and an appropriate setup of physical therapy and rehabilitation, all of which may not be available. The expatriate team may well find itself working alongside highly experienced local colleagues who will assume surgical visitors have appropriate competencies. Having a go at procedures beyond the teams competence will cause friction and ill will. Collaboration with local colleagues is a key issue. Tact is needed as visitors may encounter unfamiliar techniques and practices and should avoid adverse comment no matter how diplomatic. Visitors too may learn. In fact, in many disaster prone areas local surgeons have much to teach concerning the management of neglected and infected soft tissue injury and fractures (Fig. 5). For example, this author was first introduced to the Ilizarov technique for fracture management by surgeons working in the Balkans and Caucasus. Recovery from the disaster may involve rehabilitation of collapsed or compromised surgical services. Teams should not undertake this task singlehanded but should seek to reinforce local initiatives. Training and education is usually fertile ground for expatriate surgeons and can generate enormous good will (Fig. 6). Opportunities for making rounds and operating with local colleagues, while disparaged by some aid agency personnel, are eagerly sought by local colleagues who value the opportunity to exchange ideas and demonstrate their skills (Fig. 7).

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Similarly, there are opportunities to undertake data collection and small audit projects in collaboration with local colleagues that sometime develop into joint publications. Deployment to a natural disaster area affords expatriate surgeons a unique opportunity to gain insights into the difficulties which beset local colleagues. Upon return home, there are numerous opportunities for drawing the attention of government and non-government agencies to these problems and difficulties. However, such advocacy must be datadriven and evidence-based. It is critically important to get the facts right and to support assertions with documentation and other evidence. Charitable and humanitarian organisations increasingly insist on verifiable evidence before involvement.

CONCLUSION International humanitarian aid missions, while affording unique opportunities for meaningful help, create many pitfalls and traps. It is therefore appropriate to conclude this article with a section devoted to some useful lessons learnt by the author and his colleagues from personal experience.
NEVER DEPLOY WITHOUT GOOD INTELLIGENCE AND A CLEAR, ACHIEVABLE PLAN

Fig. 8. All that remains of a laboratory in a failed hospital in Afghanistan.

DONATION OF MEDICAL EQUIPMENT

This sound military doctrine applies no less to surgical teams on an aid mission to a natural disaster. Good preparation and planning will prevent inappropriate deployment with the ensuing embarrassment that will follow (14). The old adage is do not become a casualty yourself.
ONLY DEPLOY PERSONNEL TRAINED FOR THE TASK

One of the most important lessons, often forgotten, concerns gifts. It is best to avoid giving equipment and consumables since your team may need them. The best time to donate is when you are leaving. If you can, leave in date medicines and consumables. If you give equipment ensure that it is appropriate, can be maintained and re-supplied.
EXIT STRATEGY

Decide before you go when you are coming home and stick to that decision. Aim to leave a legacy, particularly that related to training and education. A senior aid agency colleague states Teach, then teach some more, then teach again. REFERENCES
01. Baxter P: Catastrophes natural and man-made disasters. In: Ryan JM, Mahoney PF, Greaves I and Bowyer G, Eds. Conflict and Catastrophe Medicine A Practical Guide. Chp 3, Pps 2748. Springer: London 02. Kaw LL: The July 1990 Earthquake in Baguio City. Dissertation for the Diploma of Medical Care of Catastrophes. The Society of Apothecaries of London: London, 2001 03. Cross F, Ryan JM: Report on a visit to Sri Lanka 16th to 27th January 2005. Leonard Cheshire Mission Report. Leonard Cheshire: London 2005 04. Redmond AD: Needs assessment of humanitarian crises. BMJ, 2005;330:13201322 05. Medicins Sans Frontieres. Hanquet G, Editor. Refugee Health An approach to emergency situations. MacMillan: London 1997 06. Punzalan CMK: Assessment and aftermath of the Mount Pinatabu catastrophe. Dissertation for the Diploma in the Medical Care of Catastrophes. The Society of Apothecaries of London: London, 2001 07. ochaonline.un.org 08. Boyarsky I, Shneiderman A: Natural and hybrid disasters causes, effects, and management. Top Emerg Med 2002:24(3): 125 09. Sever MS, Erek E, Vanholder R, Ozener C, Yavuz M, Kayacan M, Ergin H, Apaydin S, Cobanoglu M, Donmez O, Erdem Y,

The rule is that only surgical specialists or senior trainees should be deployed. A disaster zone is not a training ground for junior trainees to gain experience. Largely, expatriate surgeons are working alongside very senior local surgeons who are acutely aware of the skill of the visitors. Deploying agencies are therefore applying high standards when choosing volunteers, and introduce processes such as clinical audit, morbidity and mortality returns and governance (22). Many donor bodies now demand this level of supervision.
INTERVENING IN HOSPITALS

While it may be impossible to avoid taking over or reinforcing a failing hospital, do it only as a last resort. Hospitals are highly complex structures and a visiting surgical team will not be able to take over (Fig. 8). Be careful of commitments and promises. Few agencies can afford to run an entire hospital, preferring instead to run limited primary care projects, which are cheaper and less open ended (23).

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J. M. Ryan Lameire N: Lessons learned from the Marmara disaster: Time period under the rubble. Crit Care Med 2002; 30(11):24432449 Demirkiran O, Dikmen Y, Utku T, Urkmez S: Crush syndrome patients after the Marmara earthquake. Emerg Med J 2003;20: 247250 Naghi TM, Kambiz K, Sghahriar JM, Afshin T, Reza SK, Behnam P, Bahador AH: A report of injuries of Irans December 26, 2003 earthquake casualties managed in tertiary referral centres. Injury 2005;36:2732 Dries D, Perry JF: Tsunami disaster: A report from the front. Crit Care Med 2005;33(5):11781179 Maegele M, Gregor S, Steinhausen E, Bouillon B, Heiss MM. Perbix W, Wappler MD, Rixen D, Geisen J, Berger-Schreck B, Schwarz R: The long-distance tertiary air transfer and care of tsunami victims: Injury patterns and microbiological aspects Crit Care Med 2005;33(5):11361140 Hawley A: Medical interventions in catastrophes and conflict. In: Ryan JM, Mahoney PF, Greaves I and Bowyer G, Eds. Conflict and Catastrophe Medicine A Practical Guide. Chp 6, Pp 83108. Springer: London, 2002 Bricknell MCM, MacCormack: Military approach to medical planning in humanitarian operations. BMJ 2005;330:14371439 MacFarlane C, Ryan JM. Training military surgeons: A challenge for the future. Milit Med, 2002;167:260262 17. Brooks A, Butcher W, Walsh M, Lambert A, Browne J, Ryan J: The experience and training of British general surgeons in trauma surgery for the abdomen, thorax and major vessels. Ann R Coll Surg Engl, 2002;84:409413 18. Minken SL: Trauma, casualties and catastrophes. A review of the civilian and military response paradigm with an overview of past, present and future educational needs. Dissertation for the Diploma of Medical Care in Catastrophes. Society of Apothecaries: London, 2002 19. Hayward Karlsson J: Hospitals for war wounded. Geneva: ICRC, 1998 20. Coupland R: War wounds of limbs surgical management. Oxford: Butterworth Heinemann, 1993 21. Mahoney PF, Ryan JM, Brooks A, Schwab: Ballistic trauma A practical guide, 2nd ed. London: Springer-Verlag, 2004 22. Birch M, Miller S: Humanitarian assistance: standards, skills, training and experience. BMJ, 2005;330:11991201 23. Ryan JM, Mahoney PF, Macnab C: Conflict recovery and intervening in hospitals. BMJ,2005;331:278280

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Received: October 5, 2005