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Recommendations for the Next Disaster: The Role of the Emergency Surgery
Emergency Surgery Coalition (ESC): Organizations with extensive
experience in delivering surgical care in humanitarian emergencies could work
together as an ESC to support the rapid deployment of emergency surgical
BEFORE THE DISASTER
Emergency prep kits. The ESC would maintain emergency
supplies worldwide. Ideally, small-scale projects in
“hotspots” would be maintained in order to establish local
relationships and supply chains.
Prior import agreements. The ESC would work with governments
and the World Health Organization to minimize administrative delays to
the importation of surgical, anesthetic, and related medical
Training of surgical personnel. The ESC would facilitate
surgical training for humanitarian settings and share lists of qualified
personnel among its members.
Define a surgical mass disaster plan. When thousands of
victims need surgical attention, scarce surgical resources need to be
directed according to agreed priorities.
DURING THE DISASTER
Inter-agency coordination: The ESC would coordinate
emergency and referral care in a manner that reduces duplication and
fragmentation between providers.
Supply delivery. The ESC would work with government and the
World Health Organization to ensure the timely delivery of humanitarian
supplies according to collective needs assessments.
AFTER THE DISASTER
The humanitarian response to major disasters is often marred by duplication and
fragmentation, resulting in insufficient resources and services reaching the victims
. This is
particularly critical when it comes to surgical care in mass disasters, both because
the impact of surgical services on mortality requires a rapid response, and because
surgical teams are often the most difficult to recruit.
In response to the 2010 Haiti earthquake, Médecins sans Frontières
(MSF) deployed the largest surgical team in the organization's 40-year history:
in 10 weeks, over 55,000 patients were treated and over 4,000 surgical interventions
performed. The overall combined response was perhaps one of the largest non-conflict
humanitarian surgical efforts in human history. However, the delivery of care was
fraught with supply delays, a lack of appropriately experienced surgeons and
anesthesiologists, and challenges in coordinating with other
agencies—governmental, military, and non-governmental—whose priorities
and motives did not always agree. We highlight some challenges from this recent
experience and propose some ways forward to support an effective surgical
humanitarian response to future major disasters.
Improving Collaboration between Relevant Services
Surgical care was one of the primary health needs in the post-earthquake response. An
estimated quarter of a million injured victims suffered internal injuries, crushed
limbs, open wounds, and fractures . The most gravely injured
victims died instantly or shortly after the quake due to long extraction times and
the severity of their wounds. First-aid and triage stations were essential in the
first hours. Many patients needed surgical procedures such as wound debridement and
amputations—these operations were required within days. In the ensuing weeks,
surgical needs increased as more patients sought medical care, often with infected,
even gangrenous wounds. Non-trauma surgical needs such as emergency obstetrical care
escalated in the weeks to months after the quake as the pre-earthquake fragile
health care system completely collapsed.
Over 600 health agencies responded to the Haiti earthquake, but few had the relevant
experience, competence, or capacity to provide the infrastructure needed to support
emergency surgical services. A lack of coordination of services resulted in too many
agencies trying to provide the same care in the same area while other sections of
the city had no access to emergency care. Many military and humanitarian groups left
after a few weeks, leaving thousands of post-operative patients behind. MSF's
post-operative and rehabilitation hospitals were overwhelmed with patients who had
been left without follow-up for their amputated limbs, wounds, and fractures.
Referral systems were not well established. Communication between agencies was poor
and most worked in isolation from one another. Standard databases and common
definitions were not shared between agencies and the total number of operations and
interventions performed during the months after the earthquake is unknown. Rumors
circulated by media about inappropriate amputations  were difficult to confirm
or refute without reliable data.
Criticism of poor coordination is a common feature of large humanitarian disasters
from the Rwandan genocide  to the 2004 Asian tsunami , and Haiti was no different
,. The need for
improved coordination between humanitarian actors in emergencies is a long-standing
concern: efforts to formalize international oversight began with proposals to
establish a relief coordination function as part of the United Nations (UN) system
in the mid-1960s. Specifically, in 1991, the Office for the Coordination of
Humanitarian Affairs (OCHA) was created to improve inter-agency coordination . In 2005,
the cluster system was established to provide information to organizations
delivering care in different sectors such as health, water and sanitation, and food
and logistics. However, relief efforts in high-profile emergencies generate
significant media and political attention and financial support, leading to a mass
influx of actors—over 2,000 agencies responded to the Haiti earthquake
according to some estimates. The presence of such a high volume of actors with
varying motives, competencies, and specificities inevitably results in a degree of
competition and duplication among actors. Many smaller non-governmental
organizations could not function independently and drained UN resources through
demands for logistical assistance . Lack of coordination is only
part of the problem.
Proximity to the disaster is paramount to responding rapidly and reducing the
extremely high mortality that often occurs in the immediate aftermath of a disaster.
While disasters are by definition unpredictable, experienced agencies can identify a
shortlist of hotspot regions that are prone to conflicts (e.g., central Africa) or
natural disasters such as earthquakes and cyclones (e.g., Central America) and
establish small-scale medical projects in order to maintain local networks and
emergency supplies of materials and medications. This presence in Haiti prior to the
earthquake allowed MSF and other actors to respond within hours, just as the
International Committee for the Red Cross (ICRC) was among the first to deliver care
during the 2005 earthquake in Pakistan. In contrast, few agencies were present in
China prior to the 2008 Sichuan earthquake and the humanitarian surgery response
there was less effective.
The ability to rapidly import essential materials is another challenge. MSF's
ability to respond in the immediate aftermath of the Haiti earthquake was assisted
by pre-positioned stock held in Panama that arrived in Haiti the day after the
earthquake. The pre-positioning of materials at 20 major airfields across the globe
has been suggested as a way to expedite the arrival of relief . Pre-positioning requires
substantial maintenance costs and a high risk of waste as medical and food supplies
expire, but the concept has value, particularly for surgical supplies. Several
agencies could have a pre-agreement to maintain these and share their use if a
disaster were to arise. Some equipment, such as oxygen and medicines (particularly
opiates for pain relief), may be subject to importation delays; the pre-positioning
of essential supplies could be linked to international customs pre-clearance that
would allow rapid importation.
In a mass disaster, airports become congested and the short supply of cargo planes
often go to the highest bidder . In Haiti, humanitarian cargo planes were diverted from
Port-au-Prince to Santo Domingo, resulting in delays of essential surgical supplies
such as an inflatable tent hospital brought in by MSF to assist with rapid surgical
care, while high-profile media and visiting dignitaries were allowed to land at the
US military–controlled Port-au Prince airport. Delays, losses, or incomplete
reception of critical and sensitive surgery, anesthesia, and laboratory equipment
hampered the overall effectiveness of the early response.
Essential humanitarian supplies should receive priority in any major crisis. Surgical
care requires a certain amount of infrastructure that cannot be realistically
maintained in every country such as sterilization machines, operating room
equipment, surgical material, and instruments. “Portable operating room”
kits that contain the most essential material needed to begin surgery can be
hand-carried by the first wave of surgeons and anesthesiologists.
Specialists such as surgeons, anesthesiologists, traumatologists, and emergency
medicine doctors experienced in treating war wounded as well as working in
resource-limited and disaster settings are rare . Lists of these qualified
specialists should be shared among relief agencies, in addition to other key staff
such as scrub technicians, peri-operative nurses, wound nurses, physiotherapists,
and psychologists. The American College of Surgeons had lists of hundreds of
surgeons ready to be deployed to Haiti, but humanitarian agencies were reluctant to
use them because inexperience in emergency settings can be more of a liability than
a help. More recently, in the United Kingdom a register of surgeons,
anesthesiologists, emergency physicians and nurses, and supporting staff qualified
and willing to work in disasters has been established . Training for disasters is
provided by organizations such as the ICRC who lead 3-day war surgery seminars
(which can be applied to natural disasters) and courses in disaster management.
These are catered for surgeons with little to no disaster management experience, and
also include lectures on humanitarian law and human rights that are beneficial to
medical staff intending to work in disasters. ICRC also maintains several training
hospitals worldwide . It is imperative that surgical personnel interested in
volunteering in humanitarian crises are effectively prepared or have prior field
Preparing for the Next Disaster
While efforts to coordinate the multitude of actors responding to the vast needs in
emergencies will remain an ongoing concern of host governments and the UN, one of
the most important lessons to be drawn from Haiti is that not all actors are equal,
and organizational triage is needed to support prioritization of relief according to
the most urgent needs. Given the particular challenges to delivering timely surgical
assistance in emergencies, we propose the formation of the Emergency Surgery
Coalition (ESC), a group consisting of organizations with extensive experience in
delivering surgical care in man-made or natural disasters, and logistical and human
resource capacity to deliver care worldwide at immediate notice. The ESC would
facilitate coordination among major surgical providers to maximize the effectiveness
of each actor's ability to deliver assistance in a given context. The ESC would
not limit the reactivity and independence of its member organizations, and would be
governed on a rotating basis by major humanitarian surgical providers who meet on a
regular basis to ensure updated supplies and organizational and educational systems.
Recommendations for the next disaster are summarized in Box 1.
Prior to a Disaster
Prior to a disaster, the ESC could develop and maintain emergency prep kits
worldwide. A continuous supply of medications such as analgesics, anesthetics,
and antibiotics are needed and the ESC could work directly with the relevant
government authorities and other competent bodies to ensure their expeditious
delivery. It would prioritize the provision of training for surgical personnel,
especially orthopedic and plastic surgeons, to prepare them for emergency work
as an important step towards building a larger trained workforce. It could
circulate lists of qualified surgical personnel among its members.
The ESC could also define model surgical strategies and triage plans for major
disasters. When thousands of victims need surgical attention, not all can be
assisted when resources are limited. In Haiti, most surgical agencies provided
care without a specific strategy and resources may not have been utilized as
efficiently as possible. For example, some surgeons spent precious hours trying
to save the life of one patient at the expense of treating several others who
were less gravely injured.
Finally, in order to improve program monitoring and evaluation, the ESC could
encourage its members to agree upon a standard database with standard typology,
as has been promoted by other organizations .
During the Disaster
A needs assessment in the first hours after the disaster is critical to evaluate
the level of response needed and should be conducted by agencies already present
at the time of the disaster if possible. The ESC could rapidly disseminate this
information to other major providers to facilitate planning.
In a disaster setting, the ESC would improve referral and transfer systems. While
there is a need for many triage and stabilization points and a critical number
of operating theatres, specialty services such as intensive care units should be
limited in number and centralized. For example, in Haiti, one organization
provided dialysis for crush syndrome and patients from all over the city were
transferred for this service . Without an overall coordinating body, many agencies
try to provide all levels of care, resulting in duplication of some services and
a paucity of others.
There is a pressing need for better monitoring and evaluation of surgical
programs in humanitarian settings. The establishment of an inter-agency database
would permit an analysis of trends and risk factors related to mortality and
morbidity rates associated with surgical disease and interventions, and allow
for interventions to be adapted accordingly in future disasters.
Efforts must also be made to better characterize the burden of surgical disease
in crisis settings. Reliable estimates are lacking in general , and in
humanitarian emergencies in particular . While the nature and
volume of medical need in humanitarian emergencies is difficult to predict,
concerted efforts have led to the establishment of reliable datasets for the
analysis of trends in mortality and morbidity due to infectious diseases,
malnutrition, and violence 17. Recent initiatives to better estimate the global
burden of surgical disease could help to better characterize the surgical burden
of disease in humanitarian crises.
Improved surgical delivery will require pre-emptive planning and inter-agency
coordination. The ESC, comprising key players from major surgical humanitarian
agencies, is a proposal to improve surgical delivery in emergencies and could
support collaboration between surgical actors in an effort to minimize delay and
duplication in the deployment of essential surgical services in future
1. [No authors listed]
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