ORIGINAL ARTICLE
Plastic Surgery Response in Natural Disasters Susan Chung, MD, Amanda Zimmerman, MS,y Andres Gaviria,z and Deniz Dayicioglu, MD Abstract: Disasters cause untold damage and are often unpredictable; however, with proper preparation, these events can be better managed. The initial response has the greatest impact on the overall success of the relief effort. A well-trained multidisciplinary network of providers is necessary to ensure coordinated care for the victims of these mass casualty disasters. As members of this network of providers, plastic surgeons have the ability to efficiently address injuries sustained in mass casualty disasters and are a valuable member of the relief effort. The skill set of plastic surgeons includes techniques that can address injuries sustained in large-scale emergencies, such as the management of soft-tissue injury, tissue viability, facial fractures, and extremity salvage. An approach to disaster relief, the types of disasters encountered, the management of injuries related to mass casualty disasters, the role of plastic surgeons in the relief effort, and resource management are discussed. In order to improve preparedness in future mass casualty disasters, plastic surgeons should receive training during residency regarding the utilization of plastic surgery knowledge in the disaster setting. Key Words: Disaster, relief, plastic surgery, reconstruction, earthquake, mobilization, triage (J Craniofac Surg 2015;26: 1036–1041)
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atastrophes cannot be predicted or prevented but can be mitigated with proper preparation. There has been increasing attention throughout the world regarding the global economic, social, and psychological impact of major disasters.1–3 Because of the increasing globalization of the economy and health care, disaster relief is becoming a joint international effort as awareness of needs is virtually immediate. Much like national efforts, such as the National Disaster Medical System,4 a network of willing providers worldwide would promote prompt coordinated care for victims of mass casualty crisis by training and preparing for the swift mobilization of volunteers and supplies. The initial response is critical for overall success. As experts in tissue viability, facial fractures, extremity salvage, and soft-tissue injury management (which are the most common acute injuries from many disasters),5–8 plastic surgeons can efficiently address a wide spectrum of injuries sustained during a large-scale emergency and should be core members of such posttrauma surgical relief teams. With timely intervention by those who can plan prudently for future From the Division of Plastic Surgery, Department of Surgery; yMorsani College of Medicine, University of South Florida, Tampa, FL; and zUniversidad CES, Medellı´n, Antioquia, Colombia. Received November 29, 2014. Accepted for publication January 26, 2015. Address correspondence and reprint requests to Amanda Zimmerman, MS, Morsani College of Medicine, University of South Florida, 2 Tampa General Circle, 7th Floor, Tampa, FL 33606; E-mail: [email protected] No sources of financial support to disclose. The authors report no conflicts of interest. Copyright # 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001658
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surgical interventions, the extent of the injuries can be limited, valuable donor areas used sensibly, and lifeboats preserved, thereby curtailing scar, deformity, and cost and improving long-term outcomes. Plastic surgeons play a vital role in disaster relief; therefore, both planned overseas plastic surgery and disaster overseas plastic surgery should be an integral part of residency training.
APPROACH Throughout history, floods, earthquakes, tsunamis, and volcanic eruptions, as well as many other natural disasters, have ensued. These catastrophes will continue to arise, and the most worrisome feature is the unpredictability. A lack of preparedness will incalculably increase the number of human lives that will continue to be lost and/or damaged. Three cyclic phases determine the ultimate success of disaster relief: precrisis, crisis, and postcrisis.9–12 The precrisis phase involves recruiting staff, allocating resources, establishing methods of data collection, and when possible early-warning disaster monitoring. In the crisis phase, information is collected, decisions communicated, resources mobilized, and assistance coordinated. The postcrisis phase allows finalizing of data, summarizing lessons learned, and proposing adjustment of tools and resources. The success of disaster relief is determined by communication and access to reliable information.13 Disaster relief efforts are determined by the scale of the crisis. An interdisciplinary team has to quickly and efficiently establish the logistics toward making the proper approach at the disaster site. Often, clinical and operating rooms must be equipped from scratch.5 A minimum standard of care should include security, water, waste management, electricity, blood availability, and sterilization. Other vital requirements are surgical and anesthesia equipment and medications. Without these minimum standards being met, surgical interventions should not begin in disaster, humanitarian crisis, or conflict settings.5–7,14,15 Given the massive tide of injuries, plastic surgeons can provide vital services at times of crisis. Then, for the best possible outcome, rehabilitation and suitable follow-up are necessary. Although at the outset of crisis response, time is of the essence, and an understanding of the local culture may take a backseat to the urgent needs, developing culture-specific approaches will ultimately provide the best outcomes. Understanding the local context can be facilitated by conducting a preprogram needs assessment.
TYPES OF DISASTERS Among the deadliest natural disasters in recent years are devastating earthquakes in the Western and Eastern hemispheres, a tsunami, and hurricanes. Earthquakes are the most common natural disaster causing widespread destruction. In fact, most of the disasters that leave destruction versus death in their wake are earthquakes. While tsunamis often have much greater impact than hurricanes, particularly because of the suddenness, the former do not cause as many injuries, whereas the latter are more common and generally last longer, causing more protracted damage. There was a reprieve after the 1999 earthquake in Turkey. However, 5 years later, the Indonesian tsunami in 2004 was followed closely by Hurricane Katrina in 2005. The 2008 Wenchuan earthquake was not as well publicized but caused much destruction all the same. Most recently, the largest
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Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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natural disaster has been the 2010 earthquake in Haiti. This displaced millions of people. Development of societies is the best way to alleviate disasters, because it leads to the infrastructure that makes it possible to buffer and treat natural disasters. However, development is a 2-edged sword. It aggravates some risks while mitigating others. With development, less than ideal terrain (coasts, wetlands, fault lines, and river deltas) is used, as real estate becomes a more precious commodity. Thus, more life and activity are occurring in disasterprone places. When groundwater is extracted for industry, drinking, and sanitation in cities near river deltas, the ground recedes, putting it farther below sea level. Artificial barriers are erected where natural ones, such as mangrove swamps and sand dunes, are obliterated. Dykes and sea walls temper the risk of harm, but in reality they potentially endanger more people and property if they fail. It is predicted that by 2070, 7 of the 10 greatest urban concentrations of economic assets that are exposed to coastal flooding will be in developing countries (none was in 2005).17 Between 2000 and 2050, the city populations exposed to tropical cyclones or earthquakes will more than double, rising from 11% to 16% of the world’s population.18 Yet, despite concern that death rates from natural disasters are rising, they are, in fact, falling.17
TYPES OF INJURIES According to a recent literature review by Clover and Redmond,19 earthquakes are the most common cause of mass impact humanitarian disaster, and soft-tissue and fracture injuries, particularly affecting the extremities, are the most common morbidity following earthquakes. Also among the most common injury diagnoses are wound infections and head/face/brain injuries. Accordingly, the most common injury-related surgical procedures are wound debridement/skin grafting, treatment for orthopedic trauma, and surgical amputation. Initially, critical soft-tissue injuries with possible amputations may require the most surgical attention—peaking toward the end of the first week when acutely injured tissues have likely declared viability or developed an infection, with wound care predominating in the second week and beyond. In particular, earthquakes, the leading cause of natural disaster-related mortality and morbidity, cause limb injuries most commonly (60% of all injuries).7,19,20 Plastic surgeons have vast knowledge of and experience dealing with the main type of injuries encountered at natural disasters, such as soft-tissue trauma, extremities trauma, burns, and facial trauma.8 This surgical branch is the best qualified to handle soft-tissue injuries, which are the most commonly observed. This type of injury may not be life threatening but can have long-term functional complications.21,22 The Centers for Disease Control and Prevention staff members abstracted data from paper-based medical records from the Haiti 2010 earthquake. Plastic surgery procedures (skin graft, wound debridement, incision, and drainage) comprised most of the surgical procedures (46.9%) among earthquake-related injuries, followed by orthopedic (25.9%), amputation (13.0%), and neurologic spine (5.6%).23
Plastic Surgery in Natural Disasters
if given immediate treatment. Prognosis is established by the injury, not the treatment, because the setting eliminates equal opportunity. With limited personnel and supplies, effective triage of a large number of casualties can optimize use of available resources. Clinical judgment drives priority assessment. Factors to take into consideration include the general physiological condition of the patient upon arrival, the number of casualties presenting for treatment, the type of wounds to be treated (a long elapsed time to medical care eliminates major life-threatening injuries), and the time elapsed between injury and hospitalization. Some will perish despite treatment; others would survive with urgent intervention, and still others may be able to wait without compromising the chance of survival. Those with minor injuries that can be treated on a nonemergent basis need to be referred a system of outpatient management that needs to be established immediately. Indeed, an assembly line approach may be necessary for efficiency.5– 7,25–28
TREATMENT Following acute trauma management, plastic surgeons should be involved in assessing and treating injuries, bringing patients to wound closure with adjacent tissue transfer or grafts and flaps. The volume of plastic surgery activity for disaster victims is significant because disasters often cause a broad spectrum of injuries. For example, in the 1999 Turkey earthquake, more than 13% of hospital beds were occupied by patients needing plastic surgery.21 Soft-tissue trauma from injuries caused by burns, blasts, compression, crush, electricity, shear, and so on is common. Initially, wound debridement is the most common procedure performed; in addition, extremity injuries must be stabilized or amputated. In a subacute fashion, skin grafting (dermatomes are indispensable, and a noted major deficiency has been the ability to close wounds with skin grafts), fracture fixation (18% of the 2005 London bomb patients had facial fractures), and amputation revision become the more commonly needed operations.8 Those who survive the delay to definitive management should still be treated in as expedient a manner as possible because delayed treatment can lead to complications such as compartment syndromes, amputation, and renal failure caused by myonecrosis; even a neglected open fracture is still a potentially mortal injury. Early and aggressive debridement of infected and necrotic wounds is vital to reducing death and disability. Although it may be tempting to pursue primary closure of amputations, these may be predisposed to developing infections, and so major wounds should be left open for delayed closure. It is important to remember that surgical care is often a delicate balance of efficiency and intentional delay. There is inherent value in delaying operating since operating too soon, that is, before physiological and scar readiness, and too often can cause significant morbidity. Surgical haste led to irrevocable waste of tissue. There is value in not doing today what could be put off safely until tomorrow.29 The third stage involves soft-tissue reconstruction with definitive wound closure and soft-tissue cover. Contractures may be expected and should be addressed with late surgical management.
TRIAGE Triage is a 3-part process: (1) collecting physiological data including assessment of vital signs and level of consciousness, (2) collecting anatomical data and identifying ‘‘significant injuries’’ (eg, multiple long-bone fractures), and (3) assessing the mechanism of injury.24 Because of the large scale, disaster relief mandates more aggressive triage policies because the disproportionate need overwhelms the available resources. After assessing survivability (some will not be able to overcome the injury no matter what treatment is given and should be managed expectantly), priority must be extended to those who have a reasonable possibility of surviving #
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FIGURE 1. The pediatric tent of Medishare Hospital decorated with artwork made by the children.
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FIGURE 2. The adult tent of Medishare Hospital.
Wound coverage is essential for limiting the physiological burden. Negative-pressure wound therapy can be used to temporize wounds. Burn assessment should include early excision and grafting most of the time, although burns to the scalp should be managed conservatively with healing by secondary intention.30– 32 One of the most useful instruments in disaster relief is the dermatome. Splitthickness skin grafts can close wounds in a manner that requires the least amount of donor-site loss. When available, tissue adhesive should be used for securing grafts.33– 35 Broad-spectrum antibiotics should be considered because contaminated wounds are common in a disaster setting.6
THE RELIEF EFFORT Turkey On August 17, 1999, a magnitude 7.4 earthquake occurred in the Marmara region of Turkey, destroying the cities of Golcuk, Izmit, Adapazari, and Yalova. Casualties were estimated to be 70,000, including 20,000 deaths, 30,000 injured, and 20,000 missing.21 The most common types of injuries related to plastic surgery were penetrating wounds and lacerations, crush injuries with soft-tissue defects, and tendon disruptions. Multiple field hospitals were present for humanitarian support, and many patients were transported to other cities that were not affected by earthquake.21 In 2011, Van earthquake efforts were more coordinated. The most common injuries reported were crush soft-tissue injuries that required orthopedic care and plastic surgical procedures.36
Indonesia On the morning of December 26, 2004, an undersea earthquake occurred near the coast of Sumatra measuring 9.0 on the Richter scale, producing a series of tsunami waves, which led to widespread destruction of surrounding countries. Aceh, an Indonesian province closest to the site of the earthquake, incurred the most devastation. Approximately 290,000 people lost their lives in this disaster, and approximately 800,000 were made homeless.37 The Australian Government sent the Australian Defense Force to assist in an operation known as Operation Sumatra Assist. The first surgical procedures were performed in the field hospital approximately 2 weeks after the tsunami had struck. The initial
FIGURE 3. The adult tent of Medishare Hospital with volunteers working the night shift.
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FIGURE 4. The operating room of Medishare Hospital, which functioned during the 6 months of Project Medishare’s service in Haiti.
procedures performed included 17 major debridements of infected wounds, 1 cesarean delivery, and 1 emergency repair of an incarcerated inguinal hernia.37 In the subsequent weeks, the most commonly performed procedures were related to the management of softtissue wounds of the limbs sustained in the tsunami, which had subsequently developed severe infections.37 The surgical team in Sumatra did not include a plastic surgeon; however, the volume of patients requiring interventions within a plastic surgeon’s skill set underscores the important contributions plastic surgeons can bring to mass casualty disasters.
China On May 12, 2008, at 2:28 PM, an earthquake of 8.0 magnitude on the Richter scale occurred in Wenchuan County in the Sichuan Province, China. The earthquake killed 67,551, wounded 281,367, and caused 9147 individuals to go missing. Most medical facilities available were destroyed or severely damaged. The Second Military Medical University set up a field hospital 2 days following the earthquake. The medical team consisted of 2 plastic surgeons, 2 general surgeons, 5 orthopedic surgeons, 2 anesthesiologists, an obstetrician/gynecologist, and 2 medicine physicians.22 The field hospital served the community for 2 months following the earthquake. There were 1013 patients treated in the Wenchuan field hospital, with 102 (10.07%) patients seeking treatment for soft-tissue injuries.22 The extremities and the face, specifically the nose, lips, and ears, were most frequently affected. These complex wounds required skin grafting or flap reconstruction. Plastic surgery patients occupied 15% of the beds available in the hospital. The most common procedure performed was debridement and wound closure (45.09%). Other procedures performed in the field hospital included skin grafting (10.78%), local flaps (16.66%), and free flaps (10.78%).22
Haiti On January 12, 2010, a 7.0 magnitude earthquake occurred, causing more than 300,000 injuries and approximately 230,000 deaths. A team from the University of Miami, Project Medishare, arrived 2 days after the earthquake, and by the ninth day, the first relief hospital was set up. The hospital contained 3 operating rooms and 240 patient beds.9 The relief hospital was staffed with 29 plastic
FIGURE 5. A United Nations tank providing aid to the people of Haiti.
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Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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FIGURE 6. Changes in the patient population treated by the plastic surgeons of Project Medishare. Notice the transition from procedures for acute problems to procedures aimed at treating more chronic problems over the 6 months the plastic surgery teams rotated at Medishare Hospital.
surgeons divided into 25 weekly teams. During the approximately 6 months in which the hospital was in use, a total of 581 plastic and reconstructive surgery patients were treated, with 162 having injuries related to the earthquake. The most common injuries seen were fractures/dislocations (54.3%), wound infections/abscess (37%), crush injures (25.3%), head/face/brain injury (9.3%), and burns (1.9%).9 A total of 346 patients underwent surgical procedures, with the most common procedures being skin grafting, wound debridement, and incision and drainage. Plastic surgery procedures comprised 46.9% of surgical procedures in patients with earthquake-related injuries.9 In the Haiti disaster, University of Miami Project Medishare had the advantage of prior experience working in Haiti with volunteer staff and local community leaders. With this, they were able to start the coordination of a much larger volunteer effort by utilizing contacts of volunteers from previous missions. Administrators of Medishare were able to secure once-weekly plane transit from Miami directly to their hospital compound at the Port-auPrince airport. On these flights, they coordinated specialty medical teams and supplies to fill the weekly needs of the hospital. At least 1 plastic surgeon per week was assigned as leader of a plastic surgery team, and this commitment was continued for the entire 6-month period that the hospital functioned. A chief medical officer was a chief leader for all specialty groups and served as liaison between the medical teams in Haiti and the team at the University of Miami. The Web site and blog (www.plasticsurgeonsdiary.com) were used to document and chronicle the experiences of plastic surgeons who went to Haiti. For the 6 months following the earthquake, the surgeons contributed to the blog during their 1-week-long trips to Medishare Hospital. Plastic surgeons shared their experiences for that time frame; patients, conditions, and needs were documented. The most vital device in that setting was the dermatome. As time progressed, acute injuries transitioned to more chronic injuries (Figs. 1–12).
FIGURE 7. A patient with a soft-tissue defect of lateral foot and ankle, later treated with split-thickness skin grafting.
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FIGURE 8. A patient with an open tibia facture that was treated with negativepressure wound therapy.
RESOURCE MANAGEMENT The larger scale, often accompanied by limited resources, mandates a change in management with careful consideration of priorities, appropriate techniques, and reasonable goals. Initial debridement and wound coverage should be accompanied by attention to future function. Streamlining anesthesia is a critical factor in providing highefficiency plastic surgery, especially in a disaster setting. Rather than relying on general anesthesia with its high requirement for perioperative monitoring and support, regional anesthesia with peripheral nerve blocks and neuraxial techniques (spinal or epidural) can be appropriate for limb amputations, debridement, and wound care.38 This technique (1) minimizes preoperative workup, (2) reduces the need for fasting status (which, in turn, eliminates the need for intravenous fluids, which can be in limited supply and is less well-tolerated in trauma patients who are already malnourished while not changing the anesthetic implications per a Cochrane database review), (3) enhances patient safety (especially in the setting of infection), (4) facilitates rapid turnover, and (5) results in little hemodynamic compromise, which reduces the postoperative monitoring and use of postoperative mechanical ventilation and supplemental oxygen. Also, peripheral nerve blocks can provide long-lasting postoperative analgesia, which allows conservation of narcotic analgesics and low nurse-to-patient staffing ratios. This type of anesthesia approach can be dispatched rapidly, bridging to more advanced field surgical and intensive care, which takes longer to deploy and set up.15,39
FOLLOW-THROUGH Postsurgical care is as important as the planning. Clinical follow-up must be arranged on a large scale. A key challenge in disaster relief management is determining the appropriate transition from response to routine. Response efforts must come to an end with responsibility returning to the affected nation. Education of the local care providers is essential to bear the increased burden of people needing follow-up.
FIGURE 9. A patient with an open tibia fracture initially treated with negativepressure wound therapy. Notice the documentation on the patient’s leg indicating the need for free flap wound coverage. This documentation served as a form of communication between physicians.
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FIGURE 10. A patient with an exposed tibia initially treated with negativepressure wound therapy. Notice the documentation on the patient’s leg indicating the need for a gastrocnemius flap. This documentation served as a form of communication between physicians.
MOBILIZATION Medical attention must converge where the patients are. It is more efficacious to bring expertise to the area and create field hospitals rather than disperse patients to outlying centers.40 Valuable time can be lost in attempting to transport the patients. Joint efforts such as that between the International Society of Aesthetic Plastic Surgery and the LEAP Foundation41 and the Foreign Medical Team Providers described by the World Health Organization42 are creating a global resource composed of surgeons and other medical personnel who are available to respond rapidly in a coordinated fashion.10 Field hospitals that are established in the aftermath of a disaster will evolve.40 Facility and manpower requirements evolve as patient demographics change over time.43 The example of a field hospital established by Project Medishare in Port-au-Prince 48 hours after the 2010 Haiti earthquake is helpful to understanding the timeline of plastic surgery needs. Initially, nearly all patients were surgical admissions. Forty percent underwent surgery for fractures and wounds in the first week. Eight weeks after the catastrophe, the vast majority of patients were medical admissions, and the operating caseload had more than halved.39 Therefore, plastic surgery contributions can be more critical in certain established time periods following disaster. A second trend involved increasing acuity of care. Initially, children were admitted for serious or limb-threatening but usually not life-threatening, injuries. Within 2 months, one third of the patients were housed in the developing neonatal intensive care unit/ pediatric intensive care unit, and only 12% were admitted for injuries related to the earthquake.39 While preserving life and limb is paramount, cultural sensitivity is also worthy of mention. Amputation carries significant stigma in some cultures. Limb salvage has greater importance in developing countries where a loss of limb is taboo and prosthetic devices are more difficult to acquire. It has been reported that patients in disaster settings, who have received counseling that death was a real possibility, have refused critically necessary surgery or left against medical
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FIGURE 12. A patient with a soft-tissue defect of lateral ankle and leg, which demonstrated good granulation tissue with negative-pressure wound therapy and was subsequently skin grafted.
advice because of the fear of amputation. Thankfully, with rapid mobilization and proximity, the response rate of providers can be improved, and a low rate of amputation maintained.19
SHARED KNOWLEDGE Communication with coordination is instrumental to improving the global response to devastating disasters and creating a smooth transition from external help to local providers.9,13,15,24,44 The experience of plastic surgeons should be shared in a public format for the improvement and advancement of disaster relief efforts.44 Knowledge transfer can take the form of published guidelines, such as the World Health Organization’s Best Practice Guidelines on Emergency Surgical Care in Disaster Situations or the Pan-African Academy of Christian Surgeons’ Principles of Reconstructive Surgery in Africa. These advances arising from compelling situations can lead to wider applicability. For example, it is not uncommon for the innovations that arise in wartime to be adapted for the mainstream.3
CONCLUSIONS The need for a global response to disaster relief is only likely to increase because technological advances have reduced the time lag of news to travel worldwide and the rate of poor-quality development in high-risk seismic areas continues to increase with population growth and demand. According to the World Bank, a disproportionate amount of humanitarian aid is spent responding to disasters versus preventing them.45 More effort should be made to prevent the devastating impact of disasters. In the meantime, plastic surgeons who are interested in participating in the response to disaster relief worldwide should find themselves to be self-sustaining members of a multidisciplinary team that can improve both mortality and morbidity following a disaster. Goals should include a reduction in duplication and fragmentation with subsequent wasted, and maybe insufficient, resources and efforts. With proper preparation and planning, plastic surgeons can be invaluable contributors in these emergency settings that involve a tremendous amount of wounds that are within the purview of the specialty. For better preparedness overseas, plastic surgery rotations or utilization of plastic surgery knowledge in a disaster setting should be a part of the plastic surgery residency training.
REFERENCES
FIGURE 11. A patient with a soft-tissue defect of the lateral leg and ankle treated with negative-pressure wound therapy. Notice the documentation indicating when the wound vacuum-assisted closure device required changing. This documentation ensured the patient’s wound care was managed appropriately.
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4. Larson DL, Basir Z, Bruce T. Is oncologic safety compatible with a predictably viable mastectomy skin flap? Plast Reconstr Surg 2011;127:27–33 5. Smith RMDG, Antonangeli K, Arredondo N, et al. Disaster triage after the Haitian earthquake. Injury 2012;43:1811–1815 6. Yang CWH, Zhong HJ. The epidemiological analyses of trauma patients in Chongqing teaching hospitals following the Wenchuan earthquake. Injury 2009;40:488–492 7. Salimi JAM, Khaji A. Analysis of 274 patients with extremity injuries caused by the Bam earthquake. Chin J Traumatol 2009;12:10–13 8. Thakar HJPP, Rohrich RJ. The role of the plastic surgeon in disaster relief. Plast Reconstr Surg 2009;124:975–981 9. Fan KLAY, Dayicioglu D, DeGennaro VA, et al. The efficacy of online communication platforms for plastic surgeons providing extended disaster relief. Ann Plast Surg 2014;72:457–462 10. Bui TCS, Sungwon C, Sankaran S, et al. A framework for designing a global information network for multinational humanitarian assistance/ disaster relief. Inform Syst Front 2000;1:427–444 11. Zhang DZL, Nunamaker JF. A knowledge management framework for the support of decision making in humanitarian assistance/disaster relief. Knowl Inform Syst 2002;4:370–385 12. Federal Emergency Management Agency. 2011. Available at: http:// www.fema.gov 13. Garshnek VBFJ. Telecommunications systems in support of disaster medicine: applications of basic information pathways. Ann Emerg Med 1999;34:213–218 14. Chackungal SNJ, Knowlton LM, Black L, et al. Best practice guidelines on surgical response in disasters and humanitarian emergencies: report of the 2011 Humanitarian Action Summit Working Group on Surgical Issues within the Humanitarian Space. Prehosp Disaster Med 2011;26:429–437 15. Jawa RSZT, Richards AT, Young DH, et al. Facilitating safer surgery and anesthesia in a disaster zone. Am J Surg 2012;204:406–409 16. Benjamin E, Bassily-Marcus AM, Babu E, et al. Principles and practice of disaster relief: lessons from Haiti. Mt Sinai J Med 2011;78:306–318 17. Counting the cost of calamities. Economist January 14, 2012. Available at: http://www.economist.com/node/21542755. 18. Natural Hazards, Unnatural Disasters: The Economics of Effective Prevention. Sydney, Australia: Lowy Institute; 2012 19. Clover AJJB, Redmond AD. Soft tissue and musculoskeletal injuries after earthquakes; describing a role for reconstructive surgeons in an emergency response. World J Surg 2014;38:2543–2550 20. Clover -E, Saeed W, Buxton R, et al., British Association of Plastic, Reconstructive, and Aesthetic Surgeons; Medical Emergency Relief International Emergency Response Team to Haiti, January to April of 2010. Experience of an orthoplastic limb salvage team after the Haiti earthquake: analysis of caseload and early outcomes. Plast Reconstr Surg 2011;127:2373–2380 21. Wolf YB-DY, Mankuta D, Finestone A, et al. An earthquake disaster in Turkey: assessment of the need for plastic surgery services in a crisis intervention field hospital. Plast Reconstr Surg 2001;107:163–168 22. Zhang J, Ding W, Chen A, et al. The prominent role of plastic surgery in the Wenchuan earthquake disaster. J Trauma 2010;69:964–969 23. Centers for Disease Control and Prevention. Post-earthquake injuries treated at a field hospital—Haiti, 2010. MMWR Morb Mortal Wkly Rep 2011;59:1673–1677 24. Chen GLW, Liu F, Mao Q, et al. The dragon strikes: lessons from the Wenchuan earthquake. Anesth Analg 2010;110:908–915
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25. Bostick NASI, Burkle FM Jr, Hsu EB, et al. Disaster triage systems for large-scale catastrophic events. Disaster Med Public Health Preparedness 2008;2 (suppl 1):S35–S39 26. Nie HTS, Tang SY, Lau WB, et al. Triage during the week of the Sichuan earthquake: a review of utilized patient triage, care, and disposition procedures. Injury 2010;41:1074–1075 27. Xiang BCW, Liu J, Huang L, et al. Triage of pediatric injuries after the 2008 Wen-Chuan earthquake in China. J Pediatr Surg 2009;44:2273– 2277 28. Emami MJTA, Alemzadeh H, et al. Strategies in evaluation and management of Bam earthquake victims. Prehosp Disaster Med 2005;20:327–330 29. Gillies HDMDJ. The Principles and Art of Plastic Surgery. Boston, MA: Little, Brown & Co; 1957 30. Sharpe DTRA. Tangential excision of scalp burns: experience from the Bradford fire disaster. Burns 1988;14:151–155 31. Sharpe DTRA, Barclay TL, et al. Treatment of burns casualties after fire at Bradford city football ground. BMJ 1985;291:945–948 32. Sood R. Archauer & Sood’s—Burns Surgery Reconstruction & Rehabilitation.Saunders/Elsevier; 2006 33. Zaki ISL, Millard L. Split skin grafting on severely damaged skin. A technique using absorbable tissue adhesive. J Dermatol Surg Oncol 1994;20:827–829 34. Craven NMTN. An open study of tissue adhesive in full-thickness skin grafting. J Am Acad Dermatol 1999;40:607–611 35. Adler NNS. Skin graft fixation with cyanoacrylate tissue adhesive in burn patients. Burns 2007;33:803 36. Gormeli G, Gormeli CA, Guner S, et al. The clinical profile of musculoskeletal injuries associated with the 2011 Van earthquake in Turkey. Jt Dis Relat Surg 2012;23:68–71 37. Chambers AJ, Campion MJ, Courtenay BG, et al. Operation Sumatra Assist: surgery for survivors of the tsunami disaster in Indonesia. ANZ J Surg 2006;76:39–42 38. Missair AGR, Pierre E, Cooper L, et al. Surgery under extreme conditions in the aftermath of the 2010 Haiti earthquake: the importance of regional anesthesia. Prehosp Disaster Med 2010;25:487– 493 39. Burnweit CSS. Disaster response in a pediatric field hospital: lessons learned in Haiti. J Pediatr Surg 2011;46:1131–1139 40. Guidelines for the use of foreign field hospitals in the aftermath of sudden-impact, disaster. Prehosp Disaster Med 2003;18:278–290 41. The Associated Press. The International Society of Aesthetic Plastic Surgery and the LEAP Foundation have deployed 4th volunteer team to Amman, Jordan for week-long surgical mission. 2014 42. World Health Organization. Coordination and registration of providers of foreign medical teams in the humanitarian response to sudden-onset disasters: a health cluster concept paper. 2011 43. Sarani BMS, Ashburn M, Gupta R, et al. Evolution of operative interventions by two university-based surgical teams in Haiti during the first month following the earthquake. Prehosp Disaster Med 2011;26:206–211 44. Chu KSC, Trelles M, Ford N. Improving effective surgical delivery in humanitarian disasters: lessons from Haiti. PLoS Med 2011;8:e1001025 45. Global Facility for Disaster Reduction and Recovery. Managing Disaster Risks for a Resilient Future: The Sendai Report. Washington, DC: World Bank; 2012
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Plastic Surgery Response in Natural Disasters Susan Chung, MD, Amanda Zimmerman, MS,y Andres Gaviria,z and Deniz Dayicioglu, MD Abstract: Disasters cause untold damage and are often unpredictable; however, with proper preparation, these events can be better managed. The initial response has the greatest impact on the overall success of the relief effort. A well-trained multidisciplinary network of providers is necessary to ensure coordinated care for the victims of these mass casualty disasters. As members of this network of providers, plastic surgeons have the ability to efficiently address injuries sustained in mass casualty disasters and are a valuable member of the relief effort. The skill set of plastic surgeons includes techniques that can address injuries sustained in large-scale emergencies, such as the management of soft-tissue injury, tissue viability, facial fractures, and extremity salvage. An approach to disaster relief, the types of disasters encountered, the management of injuries related to mass casualty disasters, the role of plastic surgeons in the relief effort, and resource management are discussed. In order to improve preparedness in future mass casualty disasters, plastic surgeons should receive training during residency regarding the utilization of plastic surgery knowledge in the disaster setting. Key Words: Disaster, relief, plastic surgery, reconstruction, earthquake, mobilization, triage (J Craniofac Surg 2015;26: 1036–1041)
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atastrophes cannot be predicted or prevented but can be mitigated with proper preparation. There has been increasing attention throughout the world regarding the global economic, social, and psychological impact of major disasters.1–3 Because of the increasing globalization of the economy and health care, disaster relief is becoming a joint international effort as awareness of needs is virtually immediate. Much like national efforts, such as the National Disaster Medical System,4 a network of willing providers worldwide would promote prompt coordinated care for victims of mass casualty crisis by training and preparing for the swift mobilization of volunteers and supplies. The initial response is critical for overall success. As experts in tissue viability, facial fractures, extremity salvage, and soft-tissue injury management (which are the most common acute injuries from many disasters),5–8 plastic surgeons can efficiently address a wide spectrum of injuries sustained during a large-scale emergency and should be core members of such posttrauma surgical relief teams. With timely intervention by those who can plan prudently for future From the Division of Plastic Surgery, Department of Surgery; yMorsani College of Medicine, University of South Florida, Tampa, FL; and zUniversidad CES, Medellı´n, Antioquia, Colombia. Received November 29, 2014. Accepted for publication January 26, 2015. Address correspondence and reprint requests to Amanda Zimmerman, MS, Morsani College of Medicine, University of South Florida, 2 Tampa General Circle, 7th Floor, Tampa, FL 33606; E-mail: [email protected] No sources of financial support to disclose. The authors report no conflicts of interest. Copyright # 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001658
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surgical interventions, the extent of the injuries can be limited, valuable donor areas used sensibly, and lifeboats preserved, thereby curtailing scar, deformity, and cost and improving long-term outcomes. Plastic surgeons play a vital role in disaster relief; therefore, both planned overseas plastic surgery and disaster overseas plastic surgery should be an integral part of residency training.
APPROACH Throughout history, floods, earthquakes, tsunamis, and volcanic eruptions, as well as many other natural disasters, have ensued. These catastrophes will continue to arise, and the most worrisome feature is the unpredictability. A lack of preparedness will incalculably increase the number of human lives that will continue to be lost and/or damaged. Three cyclic phases determine the ultimate success of disaster relief: precrisis, crisis, and postcrisis.9–12 The precrisis phase involves recruiting staff, allocating resources, establishing methods of data collection, and when possible early-warning disaster monitoring. In the crisis phase, information is collected, decisions communicated, resources mobilized, and assistance coordinated. The postcrisis phase allows finalizing of data, summarizing lessons learned, and proposing adjustment of tools and resources. The success of disaster relief is determined by communication and access to reliable information.13 Disaster relief efforts are determined by the scale of the crisis. An interdisciplinary team has to quickly and efficiently establish the logistics toward making the proper approach at the disaster site. Often, clinical and operating rooms must be equipped from scratch.5 A minimum standard of care should include security, water, waste management, electricity, blood availability, and sterilization. Other vital requirements are surgical and anesthesia equipment and medications. Without these minimum standards being met, surgical interventions should not begin in disaster, humanitarian crisis, or conflict settings.5–7,14,15 Given the massive tide of injuries, plastic surgeons can provide vital services at times of crisis. Then, for the best possible outcome, rehabilitation and suitable follow-up are necessary. Although at the outset of crisis response, time is of the essence, and an understanding of the local culture may take a backseat to the urgent needs, developing culture-specific approaches will ultimately provide the best outcomes. Understanding the local context can be facilitated by conducting a preprogram needs assessment.
TYPES OF DISASTERS Among the deadliest natural disasters in recent years are devastating earthquakes in the Western and Eastern hemispheres, a tsunami, and hurricanes. Earthquakes are the most common natural disaster causing widespread destruction. In fact, most of the disasters that leave destruction versus death in their wake are earthquakes. While tsunamis often have much greater impact than hurricanes, particularly because of the suddenness, the former do not cause as many injuries, whereas the latter are more common and generally last longer, causing more protracted damage. There was a reprieve after the 1999 earthquake in Turkey. However, 5 years later, the Indonesian tsunami in 2004 was followed closely by Hurricane Katrina in 2005. The 2008 Wenchuan earthquake was not as well publicized but caused much destruction all the same. Most recently, the largest
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natural disaster has been the 2010 earthquake in Haiti. This displaced millions of people. Development of societies is the best way to alleviate disasters, because it leads to the infrastructure that makes it possible to buffer and treat natural disasters. However, development is a 2-edged sword. It aggravates some risks while mitigating others. With development, less than ideal terrain (coasts, wetlands, fault lines, and river deltas) is used, as real estate becomes a more precious commodity. Thus, more life and activity are occurring in disasterprone places. When groundwater is extracted for industry, drinking, and sanitation in cities near river deltas, the ground recedes, putting it farther below sea level. Artificial barriers are erected where natural ones, such as mangrove swamps and sand dunes, are obliterated. Dykes and sea walls temper the risk of harm, but in reality they potentially endanger more people and property if they fail. It is predicted that by 2070, 7 of the 10 greatest urban concentrations of economic assets that are exposed to coastal flooding will be in developing countries (none was in 2005).17 Between 2000 and 2050, the city populations exposed to tropical cyclones or earthquakes will more than double, rising from 11% to 16% of the world’s population.18 Yet, despite concern that death rates from natural disasters are rising, they are, in fact, falling.17
TYPES OF INJURIES According to a recent literature review by Clover and Redmond,19 earthquakes are the most common cause of mass impact humanitarian disaster, and soft-tissue and fracture injuries, particularly affecting the extremities, are the most common morbidity following earthquakes. Also among the most common injury diagnoses are wound infections and head/face/brain injuries. Accordingly, the most common injury-related surgical procedures are wound debridement/skin grafting, treatment for orthopedic trauma, and surgical amputation. Initially, critical soft-tissue injuries with possible amputations may require the most surgical attention—peaking toward the end of the first week when acutely injured tissues have likely declared viability or developed an infection, with wound care predominating in the second week and beyond. In particular, earthquakes, the leading cause of natural disaster-related mortality and morbidity, cause limb injuries most commonly (60% of all injuries).7,19,20 Plastic surgeons have vast knowledge of and experience dealing with the main type of injuries encountered at natural disasters, such as soft-tissue trauma, extremities trauma, burns, and facial trauma.8 This surgical branch is the best qualified to handle soft-tissue injuries, which are the most commonly observed. This type of injury may not be life threatening but can have long-term functional complications.21,22 The Centers for Disease Control and Prevention staff members abstracted data from paper-based medical records from the Haiti 2010 earthquake. Plastic surgery procedures (skin graft, wound debridement, incision, and drainage) comprised most of the surgical procedures (46.9%) among earthquake-related injuries, followed by orthopedic (25.9%), amputation (13.0%), and neurologic spine (5.6%).23
Plastic Surgery in Natural Disasters
if given immediate treatment. Prognosis is established by the injury, not the treatment, because the setting eliminates equal opportunity. With limited personnel and supplies, effective triage of a large number of casualties can optimize use of available resources. Clinical judgment drives priority assessment. Factors to take into consideration include the general physiological condition of the patient upon arrival, the number of casualties presenting for treatment, the type of wounds to be treated (a long elapsed time to medical care eliminates major life-threatening injuries), and the time elapsed between injury and hospitalization. Some will perish despite treatment; others would survive with urgent intervention, and still others may be able to wait without compromising the chance of survival. Those with minor injuries that can be treated on a nonemergent basis need to be referred a system of outpatient management that needs to be established immediately. Indeed, an assembly line approach may be necessary for efficiency.5– 7,25–28
TREATMENT Following acute trauma management, plastic surgeons should be involved in assessing and treating injuries, bringing patients to wound closure with adjacent tissue transfer or grafts and flaps. The volume of plastic surgery activity for disaster victims is significant because disasters often cause a broad spectrum of injuries. For example, in the 1999 Turkey earthquake, more than 13% of hospital beds were occupied by patients needing plastic surgery.21 Soft-tissue trauma from injuries caused by burns, blasts, compression, crush, electricity, shear, and so on is common. Initially, wound debridement is the most common procedure performed; in addition, extremity injuries must be stabilized or amputated. In a subacute fashion, skin grafting (dermatomes are indispensable, and a noted major deficiency has been the ability to close wounds with skin grafts), fracture fixation (18% of the 2005 London bomb patients had facial fractures), and amputation revision become the more commonly needed operations.8 Those who survive the delay to definitive management should still be treated in as expedient a manner as possible because delayed treatment can lead to complications such as compartment syndromes, amputation, and renal failure caused by myonecrosis; even a neglected open fracture is still a potentially mortal injury. Early and aggressive debridement of infected and necrotic wounds is vital to reducing death and disability. Although it may be tempting to pursue primary closure of amputations, these may be predisposed to developing infections, and so major wounds should be left open for delayed closure. It is important to remember that surgical care is often a delicate balance of efficiency and intentional delay. There is inherent value in delaying operating since operating too soon, that is, before physiological and scar readiness, and too often can cause significant morbidity. Surgical haste led to irrevocable waste of tissue. There is value in not doing today what could be put off safely until tomorrow.29 The third stage involves soft-tissue reconstruction with definitive wound closure and soft-tissue cover. Contractures may be expected and should be addressed with late surgical management.
TRIAGE Triage is a 3-part process: (1) collecting physiological data including assessment of vital signs and level of consciousness, (2) collecting anatomical data and identifying ‘‘significant injuries’’ (eg, multiple long-bone fractures), and (3) assessing the mechanism of injury.24 Because of the large scale, disaster relief mandates more aggressive triage policies because the disproportionate need overwhelms the available resources. After assessing survivability (some will not be able to overcome the injury no matter what treatment is given and should be managed expectantly), priority must be extended to those who have a reasonable possibility of surviving #
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FIGURE 1. The pediatric tent of Medishare Hospital decorated with artwork made by the children.
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FIGURE 2. The adult tent of Medishare Hospital.
Wound coverage is essential for limiting the physiological burden. Negative-pressure wound therapy can be used to temporize wounds. Burn assessment should include early excision and grafting most of the time, although burns to the scalp should be managed conservatively with healing by secondary intention.30– 32 One of the most useful instruments in disaster relief is the dermatome. Splitthickness skin grafts can close wounds in a manner that requires the least amount of donor-site loss. When available, tissue adhesive should be used for securing grafts.33– 35 Broad-spectrum antibiotics should be considered because contaminated wounds are common in a disaster setting.6
THE RELIEF EFFORT Turkey On August 17, 1999, a magnitude 7.4 earthquake occurred in the Marmara region of Turkey, destroying the cities of Golcuk, Izmit, Adapazari, and Yalova. Casualties were estimated to be 70,000, including 20,000 deaths, 30,000 injured, and 20,000 missing.21 The most common types of injuries related to plastic surgery were penetrating wounds and lacerations, crush injuries with soft-tissue defects, and tendon disruptions. Multiple field hospitals were present for humanitarian support, and many patients were transported to other cities that were not affected by earthquake.21 In 2011, Van earthquake efforts were more coordinated. The most common injuries reported were crush soft-tissue injuries that required orthopedic care and plastic surgical procedures.36
Indonesia On the morning of December 26, 2004, an undersea earthquake occurred near the coast of Sumatra measuring 9.0 on the Richter scale, producing a series of tsunami waves, which led to widespread destruction of surrounding countries. Aceh, an Indonesian province closest to the site of the earthquake, incurred the most devastation. Approximately 290,000 people lost their lives in this disaster, and approximately 800,000 were made homeless.37 The Australian Government sent the Australian Defense Force to assist in an operation known as Operation Sumatra Assist. The first surgical procedures were performed in the field hospital approximately 2 weeks after the tsunami had struck. The initial
FIGURE 3. The adult tent of Medishare Hospital with volunteers working the night shift.
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FIGURE 4. The operating room of Medishare Hospital, which functioned during the 6 months of Project Medishare’s service in Haiti.
procedures performed included 17 major debridements of infected wounds, 1 cesarean delivery, and 1 emergency repair of an incarcerated inguinal hernia.37 In the subsequent weeks, the most commonly performed procedures were related to the management of softtissue wounds of the limbs sustained in the tsunami, which had subsequently developed severe infections.37 The surgical team in Sumatra did not include a plastic surgeon; however, the volume of patients requiring interventions within a plastic surgeon’s skill set underscores the important contributions plastic surgeons can bring to mass casualty disasters.
China On May 12, 2008, at 2:28 PM, an earthquake of 8.0 magnitude on the Richter scale occurred in Wenchuan County in the Sichuan Province, China. The earthquake killed 67,551, wounded 281,367, and caused 9147 individuals to go missing. Most medical facilities available were destroyed or severely damaged. The Second Military Medical University set up a field hospital 2 days following the earthquake. The medical team consisted of 2 plastic surgeons, 2 general surgeons, 5 orthopedic surgeons, 2 anesthesiologists, an obstetrician/gynecologist, and 2 medicine physicians.22 The field hospital served the community for 2 months following the earthquake. There were 1013 patients treated in the Wenchuan field hospital, with 102 (10.07%) patients seeking treatment for soft-tissue injuries.22 The extremities and the face, specifically the nose, lips, and ears, were most frequently affected. These complex wounds required skin grafting or flap reconstruction. Plastic surgery patients occupied 15% of the beds available in the hospital. The most common procedure performed was debridement and wound closure (45.09%). Other procedures performed in the field hospital included skin grafting (10.78%), local flaps (16.66%), and free flaps (10.78%).22
Haiti On January 12, 2010, a 7.0 magnitude earthquake occurred, causing more than 300,000 injuries and approximately 230,000 deaths. A team from the University of Miami, Project Medishare, arrived 2 days after the earthquake, and by the ninth day, the first relief hospital was set up. The hospital contained 3 operating rooms and 240 patient beds.9 The relief hospital was staffed with 29 plastic
FIGURE 5. A United Nations tank providing aid to the people of Haiti.
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Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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FIGURE 6. Changes in the patient population treated by the plastic surgeons of Project Medishare. Notice the transition from procedures for acute problems to procedures aimed at treating more chronic problems over the 6 months the plastic surgery teams rotated at Medishare Hospital.
surgeons divided into 25 weekly teams. During the approximately 6 months in which the hospital was in use, a total of 581 plastic and reconstructive surgery patients were treated, with 162 having injuries related to the earthquake. The most common injuries seen were fractures/dislocations (54.3%), wound infections/abscess (37%), crush injures (25.3%), head/face/brain injury (9.3%), and burns (1.9%).9 A total of 346 patients underwent surgical procedures, with the most common procedures being skin grafting, wound debridement, and incision and drainage. Plastic surgery procedures comprised 46.9% of surgical procedures in patients with earthquake-related injuries.9 In the Haiti disaster, University of Miami Project Medishare had the advantage of prior experience working in Haiti with volunteer staff and local community leaders. With this, they were able to start the coordination of a much larger volunteer effort by utilizing contacts of volunteers from previous missions. Administrators of Medishare were able to secure once-weekly plane transit from Miami directly to their hospital compound at the Port-auPrince airport. On these flights, they coordinated specialty medical teams and supplies to fill the weekly needs of the hospital. At least 1 plastic surgeon per week was assigned as leader of a plastic surgery team, and this commitment was continued for the entire 6-month period that the hospital functioned. A chief medical officer was a chief leader for all specialty groups and served as liaison between the medical teams in Haiti and the team at the University of Miami. The Web site and blog (www.plasticsurgeonsdiary.com) were used to document and chronicle the experiences of plastic surgeons who went to Haiti. For the 6 months following the earthquake, the surgeons contributed to the blog during their 1-week-long trips to Medishare Hospital. Plastic surgeons shared their experiences for that time frame; patients, conditions, and needs were documented. The most vital device in that setting was the dermatome. As time progressed, acute injuries transitioned to more chronic injuries (Figs. 1–12).
FIGURE 7. A patient with a soft-tissue defect of lateral foot and ankle, later treated with split-thickness skin grafting.
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FIGURE 8. A patient with an open tibia facture that was treated with negativepressure wound therapy.
RESOURCE MANAGEMENT The larger scale, often accompanied by limited resources, mandates a change in management with careful consideration of priorities, appropriate techniques, and reasonable goals. Initial debridement and wound coverage should be accompanied by attention to future function. Streamlining anesthesia is a critical factor in providing highefficiency plastic surgery, especially in a disaster setting. Rather than relying on general anesthesia with its high requirement for perioperative monitoring and support, regional anesthesia with peripheral nerve blocks and neuraxial techniques (spinal or epidural) can be appropriate for limb amputations, debridement, and wound care.38 This technique (1) minimizes preoperative workup, (2) reduces the need for fasting status (which, in turn, eliminates the need for intravenous fluids, which can be in limited supply and is less well-tolerated in trauma patients who are already malnourished while not changing the anesthetic implications per a Cochrane database review), (3) enhances patient safety (especially in the setting of infection), (4) facilitates rapid turnover, and (5) results in little hemodynamic compromise, which reduces the postoperative monitoring and use of postoperative mechanical ventilation and supplemental oxygen. Also, peripheral nerve blocks can provide long-lasting postoperative analgesia, which allows conservation of narcotic analgesics and low nurse-to-patient staffing ratios. This type of anesthesia approach can be dispatched rapidly, bridging to more advanced field surgical and intensive care, which takes longer to deploy and set up.15,39
FOLLOW-THROUGH Postsurgical care is as important as the planning. Clinical follow-up must be arranged on a large scale. A key challenge in disaster relief management is determining the appropriate transition from response to routine. Response efforts must come to an end with responsibility returning to the affected nation. Education of the local care providers is essential to bear the increased burden of people needing follow-up.
FIGURE 9. A patient with an open tibia fracture initially treated with negativepressure wound therapy. Notice the documentation on the patient’s leg indicating the need for free flap wound coverage. This documentation served as a form of communication between physicians.
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FIGURE 10. A patient with an exposed tibia initially treated with negativepressure wound therapy. Notice the documentation on the patient’s leg indicating the need for a gastrocnemius flap. This documentation served as a form of communication between physicians.
MOBILIZATION Medical attention must converge where the patients are. It is more efficacious to bring expertise to the area and create field hospitals rather than disperse patients to outlying centers.40 Valuable time can be lost in attempting to transport the patients. Joint efforts such as that between the International Society of Aesthetic Plastic Surgery and the LEAP Foundation41 and the Foreign Medical Team Providers described by the World Health Organization42 are creating a global resource composed of surgeons and other medical personnel who are available to respond rapidly in a coordinated fashion.10 Field hospitals that are established in the aftermath of a disaster will evolve.40 Facility and manpower requirements evolve as patient demographics change over time.43 The example of a field hospital established by Project Medishare in Port-au-Prince 48 hours after the 2010 Haiti earthquake is helpful to understanding the timeline of plastic surgery needs. Initially, nearly all patients were surgical admissions. Forty percent underwent surgery for fractures and wounds in the first week. Eight weeks after the catastrophe, the vast majority of patients were medical admissions, and the operating caseload had more than halved.39 Therefore, plastic surgery contributions can be more critical in certain established time periods following disaster. A second trend involved increasing acuity of care. Initially, children were admitted for serious or limb-threatening but usually not life-threatening, injuries. Within 2 months, one third of the patients were housed in the developing neonatal intensive care unit/ pediatric intensive care unit, and only 12% were admitted for injuries related to the earthquake.39 While preserving life and limb is paramount, cultural sensitivity is also worthy of mention. Amputation carries significant stigma in some cultures. Limb salvage has greater importance in developing countries where a loss of limb is taboo and prosthetic devices are more difficult to acquire. It has been reported that patients in disaster settings, who have received counseling that death was a real possibility, have refused critically necessary surgery or left against medical
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FIGURE 12. A patient with a soft-tissue defect of lateral ankle and leg, which demonstrated good granulation tissue with negative-pressure wound therapy and was subsequently skin grafted.
advice because of the fear of amputation. Thankfully, with rapid mobilization and proximity, the response rate of providers can be improved, and a low rate of amputation maintained.19
SHARED KNOWLEDGE Communication with coordination is instrumental to improving the global response to devastating disasters and creating a smooth transition from external help to local providers.9,13,15,24,44 The experience of plastic surgeons should be shared in a public format for the improvement and advancement of disaster relief efforts.44 Knowledge transfer can take the form of published guidelines, such as the World Health Organization’s Best Practice Guidelines on Emergency Surgical Care in Disaster Situations or the Pan-African Academy of Christian Surgeons’ Principles of Reconstructive Surgery in Africa. These advances arising from compelling situations can lead to wider applicability. For example, it is not uncommon for the innovations that arise in wartime to be adapted for the mainstream.3
CONCLUSIONS The need for a global response to disaster relief is only likely to increase because technological advances have reduced the time lag of news to travel worldwide and the rate of poor-quality development in high-risk seismic areas continues to increase with population growth and demand. According to the World Bank, a disproportionate amount of humanitarian aid is spent responding to disasters versus preventing them.45 More effort should be made to prevent the devastating impact of disasters. In the meantime, plastic surgeons who are interested in participating in the response to disaster relief worldwide should find themselves to be self-sustaining members of a multidisciplinary team that can improve both mortality and morbidity following a disaster. Goals should include a reduction in duplication and fragmentation with subsequent wasted, and maybe insufficient, resources and efforts. With proper preparation and planning, plastic surgeons can be invaluable contributors in these emergency settings that involve a tremendous amount of wounds that are within the purview of the specialty. For better preparedness overseas, plastic surgery rotations or utilization of plastic surgery knowledge in a disaster setting should be a part of the plastic surgery residency training.
REFERENCES
FIGURE 11. A patient with a soft-tissue defect of the lateral leg and ankle treated with negative-pressure wound therapy. Notice the documentation indicating when the wound vacuum-assisted closure device required changing. This documentation ensured the patient’s wound care was managed appropriately.
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4. Larson DL, Basir Z, Bruce T. Is oncologic safety compatible with a predictably viable mastectomy skin flap? Plast Reconstr Surg 2011;127:27–33 5. Smith RMDG, Antonangeli K, Arredondo N, et al. Disaster triage after the Haitian earthquake. Injury 2012;43:1811–1815 6. Yang CWH, Zhong HJ. The epidemiological analyses of trauma patients in Chongqing teaching hospitals following the Wenchuan earthquake. Injury 2009;40:488–492 7. Salimi JAM, Khaji A. Analysis of 274 patients with extremity injuries caused by the Bam earthquake. Chin J Traumatol 2009;12:10–13 8. Thakar HJPP, Rohrich RJ. The role of the plastic surgeon in disaster relief. Plast Reconstr Surg 2009;124:975–981 9. Fan KLAY, Dayicioglu D, DeGennaro VA, et al. The efficacy of online communication platforms for plastic surgeons providing extended disaster relief. Ann Plast Surg 2014;72:457–462 10. Bui TCS, Sungwon C, Sankaran S, et al. A framework for designing a global information network for multinational humanitarian assistance/ disaster relief. Inform Syst Front 2000;1:427–444 11. Zhang DZL, Nunamaker JF. A knowledge management framework for the support of decision making in humanitarian assistance/disaster relief. Knowl Inform Syst 2002;4:370–385 12. Federal Emergency Management Agency. 2011. Available at: http:// www.fema.gov 13. Garshnek VBFJ. Telecommunications systems in support of disaster medicine: applications of basic information pathways. Ann Emerg Med 1999;34:213–218 14. Chackungal SNJ, Knowlton LM, Black L, et al. Best practice guidelines on surgical response in disasters and humanitarian emergencies: report of the 2011 Humanitarian Action Summit Working Group on Surgical Issues within the Humanitarian Space. Prehosp Disaster Med 2011;26:429–437 15. Jawa RSZT, Richards AT, Young DH, et al. Facilitating safer surgery and anesthesia in a disaster zone. Am J Surg 2012;204:406–409 16. Benjamin E, Bassily-Marcus AM, Babu E, et al. Principles and practice of disaster relief: lessons from Haiti. Mt Sinai J Med 2011;78:306–318 17. Counting the cost of calamities. Economist January 14, 2012. Available at: http://www.economist.com/node/21542755. 18. Natural Hazards, Unnatural Disasters: The Economics of Effective Prevention. Sydney, Australia: Lowy Institute; 2012 19. Clover AJJB, Redmond AD. Soft tissue and musculoskeletal injuries after earthquakes; describing a role for reconstructive surgeons in an emergency response. World J Surg 2014;38:2543–2550 20. Clover -E, Saeed W, Buxton R, et al., British Association of Plastic, Reconstructive, and Aesthetic Surgeons; Medical Emergency Relief International Emergency Response Team to Haiti, January to April of 2010. Experience of an orthoplastic limb salvage team after the Haiti earthquake: analysis of caseload and early outcomes. Plast Reconstr Surg 2011;127:2373–2380 21. Wolf YB-DY, Mankuta D, Finestone A, et al. An earthquake disaster in Turkey: assessment of the need for plastic surgery services in a crisis intervention field hospital. Plast Reconstr Surg 2001;107:163–168 22. Zhang J, Ding W, Chen A, et al. The prominent role of plastic surgery in the Wenchuan earthquake disaster. J Trauma 2010;69:964–969 23. Centers for Disease Control and Prevention. Post-earthquake injuries treated at a field hospital—Haiti, 2010. MMWR Morb Mortal Wkly Rep 2011;59:1673–1677 24. Chen GLW, Liu F, Mao Q, et al. The dragon strikes: lessons from the Wenchuan earthquake. Anesth Analg 2010;110:908–915
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25. Bostick NASI, Burkle FM Jr, Hsu EB, et al. Disaster triage systems for large-scale catastrophic events. Disaster Med Public Health Preparedness 2008;2 (suppl 1):S35–S39 26. Nie HTS, Tang SY, Lau WB, et al. Triage during the week of the Sichuan earthquake: a review of utilized patient triage, care, and disposition procedures. Injury 2010;41:1074–1075 27. Xiang BCW, Liu J, Huang L, et al. Triage of pediatric injuries after the 2008 Wen-Chuan earthquake in China. J Pediatr Surg 2009;44:2273– 2277 28. Emami MJTA, Alemzadeh H, et al. Strategies in evaluation and management of Bam earthquake victims. Prehosp Disaster Med 2005;20:327–330 29. Gillies HDMDJ. The Principles and Art of Plastic Surgery. Boston, MA: Little, Brown & Co; 1957 30. Sharpe DTRA. Tangential excision of scalp burns: experience from the Bradford fire disaster. Burns 1988;14:151–155 31. Sharpe DTRA, Barclay TL, et al. Treatment of burns casualties after fire at Bradford city football ground. BMJ 1985;291:945–948 32. Sood R. Archauer & Sood’s—Burns Surgery Reconstruction & Rehabilitation.Saunders/Elsevier; 2006 33. Zaki ISL, Millard L. Split skin grafting on severely damaged skin. A technique using absorbable tissue adhesive. J Dermatol Surg Oncol 1994;20:827–829 34. Craven NMTN. An open study of tissue adhesive in full-thickness skin grafting. J Am Acad Dermatol 1999;40:607–611 35. Adler NNS. Skin graft fixation with cyanoacrylate tissue adhesive in burn patients. Burns 2007;33:803 36. Gormeli G, Gormeli CA, Guner S, et al. The clinical profile of musculoskeletal injuries associated with the 2011 Van earthquake in Turkey. Jt Dis Relat Surg 2012;23:68–71 37. Chambers AJ, Campion MJ, Courtenay BG, et al. Operation Sumatra Assist: surgery for survivors of the tsunami disaster in Indonesia. ANZ J Surg 2006;76:39–42 38. Missair AGR, Pierre E, Cooper L, et al. Surgery under extreme conditions in the aftermath of the 2010 Haiti earthquake: the importance of regional anesthesia. Prehosp Disaster Med 2010;25:487– 493 39. Burnweit CSS. Disaster response in a pediatric field hospital: lessons learned in Haiti. J Pediatr Surg 2011;46:1131–1139 40. Guidelines for the use of foreign field hospitals in the aftermath of sudden-impact, disaster. Prehosp Disaster Med 2003;18:278–290 41. The Associated Press. The International Society of Aesthetic Plastic Surgery and the LEAP Foundation have deployed 4th volunteer team to Amman, Jordan for week-long surgical mission. 2014 42. World Health Organization. Coordination and registration of providers of foreign medical teams in the humanitarian response to sudden-onset disasters: a health cluster concept paper. 2011 43. Sarani BMS, Ashburn M, Gupta R, et al. Evolution of operative interventions by two university-based surgical teams in Haiti during the first month following the earthquake. Prehosp Disaster Med 2011;26:206–211 44. Chu KSC, Trelles M, Ford N. Improving effective surgical delivery in humanitarian disasters: lessons from Haiti. PLoS Med 2011;8:e1001025 45. Global Facility for Disaster Reduction and Recovery. Managing Disaster Risks for a Resilient Future: The Sendai Report. Washington, DC: World Bank; 2012
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