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 Thursday’s “Disaster-Relief Orthopaedics” symposium.

CDR Matthew T. Provencher, MD, MC, USN

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 that we don’t normally even think about must be addressed.”

Communication, in particular, is a concern. Recalling the devastation caused by Hurricane Katrina in 2005, Dr. Provencher noted that when cell towers were torn down, 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 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. Noting 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 told the audience. Dr. Hayda emphasized the importance of advance preparations. “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, he said, 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 both time-intensive and 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.

Knowing a little about the people, their customs, their language, and local standards is helpful. If you don’t speak the language, he advises, get a translator—just an electronic, handheld translator is helpful.

Even in countries other than the United States, informed consent is important. 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

Successful volunteers
According to CDR Trent Douglas, 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 this is not a vacation.

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

But he also noted that providing care in a catastrophic situation can seem inherently unfair because you simply cannot help everyone. It is important to realize your personal limitations, as well as the limitations of the site and your mission. “Everyone has a role,” he said, “and as a team, we must utilize each individual’s strengths.”

He left the audience with 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.

Are you ready?
After the general presentations, LtCol Warren R. Kadrmas, MD, MC, USAF, covered specific injuries disaster volunteers would likely encounter: compartment syndrome, burns, and vascular evaluation and treatment. The faculty then ran down several case scenarios, such as a tsunami, suicide bomber, and an earthquake. They reviewed the type of injuries that might result and engaged the audience in a discussion about the role of the orthopaedist, how to integrate with a multinational, multispecialty team, and what to expect—particularly as compared to a “normal” practice.

Disclosure information: Drs. Douglas, Ficke, and Provencher—no conflicts; Dr. Hayda—ANOA, BioIntraface; Dr. Kadrmas—Pivot Medical.

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.

Prepared by Mary Ann Porucznik, managing editor, AAOS Now.