Global health, global surgery and mass casualties. I. Rationale for integrated mass casualty centres (original) (raw)
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BMJ Global Health
Trauma/stroke centres optimise acute 24/7/365 surgical/critical care in high-income countries (HICs). Concepts from low-income and middle-income countries (LMICs) offer additional cost-effective healthcare strategies for limited-resource settings when combined with the trauma/stroke centre concept. Mass casualty centres (MCCs) integrate resources for both routine and emergency care—from prevention to acute care to rehabilitation. Integration of the various healthcare systems—governmental, non-governmental and military—is key to avoid both duplication and gaps. With input from LMIC and HIC personnel of various backgrounds—trauma and subspecialty surgery, nursing, information technology and telemedicine, and healthcare administration—creative solutions to the challenges of expanding care (both daily and disaster) are developed. MCCs are evolving initially in Chile and Pakistan. Technologies for cost-effective healthcare in LMICs include smartphone apps (enhance prehospital care) to el...
Tropical medicine & international health : TM & IH, 2015
The global burden of trauma and surgical conditions fall disproportionately on low- and middle-income countries (LMICs).(1, 2) Inopportunely, developing countries are least equipped to provide essential surgical care.(3) Consequently, LMICs have a significant burden of unmet surgical needs.(4) When these fragile health systems are disrupted by conflict, a natural disaster or an epidemic the volume and quality of surgical care decreases even further. This article is protected by copyright. All rights reserved.
Prehospital and Disaster Medicine, 2012
Objective: Humanitarian surgery is often organized and delivered with short notice and limited time for developing unique strategies for providing care. While some surgical pathologies can be anticipated by the nature of the crisis, the role of foreign medical teams in treating the existing and unmet burden of surgical disease during crises is unclear. The purpose of this study was to examine published data from crises during the years 1990 through 2011 to understand the role of foreign medical teams in providing surgical care in these settings. Methods: A literature search was completed using PubMed, MEDLINE, and EMBASE databases to locate relevant manuscripts published in peer-reviewed journals. A qualitative review of the surgical activities reported in the studies was performed. Results: Of 185 papers where humanitarian surgical care was provided by a foreign medical team, only 11 articles met inclusion criteria. The reporting of surgical activities varied significantly, and pooled statistical analysis was not possible. The quality of reporting was notably poor, and produced neither reliable estimates of the pattern of surgical consultations nor data on the epidemiology of the burden of surgical diseases. The qualitative trend analysis revealed that the most frequent procedures were related to soft tissue or orthopedic surgery. Procedures such as caesarean sections, hernia repairs, and appendectomies also were common. As length of deployment increased, the surgical caseload became more reflective of the existing, unmet burden of surgical disease. Conclusions: This review suggests that where foreign medical teams are indicated and requested, multidisciplinary surgical teams capable of providing a range of emergency and essential surgical, and rehabilitation services are required. Standardization of data collection and reporting tools for surgical care are needed to improve the reporting of surgical epidemiology in crisis-affected populations.
Surgery, 2015
Operative trauma in low-resource settings: The experience of Médecins Sans Frontières in environments of conflict, postconflict, and disaster. 2015, 157 (5):850-6 Surgery Democratic Republic of the Congo, Tabarre, Port-au-Prince, Ha€ ıti, Timurgara, Lower Dir, Pakistan, Jabal-Akkrad, Syria, and Baltimore, MD Background. Conflicts and disasters remain prevalent in low-and middle-income countries, and injury remains a leading cause of death worldwide. The objective of this study was to describe the operative procedures performed for injury-related pathologies at facilities supported by M edecins Sans Fronti eres (MSF) to guide the planning of future responses. Methods. A retrospective review of a prospectively collected database of all MSF procedures performed between July 2008 and June 2014 for injury-related indications was completed. Individual data points included country of project and date of procedure; age, patient sex, and the American Society of Anesthesiologists' score of each patient; indication for surgery, including mechanism of injury; operative procedure; operative urgency; operative order; type of anesthesia; and intraoperative mortality. Injury severity was stratified according to operative order and urgency. Results. A total of 79,715 procedures were performed in MSF projects that met the inclusion criteria. Of these, 35,756 (44.9%) were performed specifically for traumatic indications across 17 countries. Even after excluding trauma centers, 29.4% (18,329/62,288) of operative cases were for injuries. Operative trauma procedures were performed most commonly for road traffic injuries (29.9%; 10,686/35,756). The most common procedure for acute trauma was extensive wound debridement (31.6%; 3,165/ 10,022) whereas burn dressings were the most frequent planned reoperation (27.1%; 4,361/16,078). Conclusion. Trauma remains an important component of the operative care provided in humanitarian assistance. This review of procedures performed by MSF in a variety of settings provides valuable insight into demographics of trauma patients, mechanisms of injury, and surgical capabilities required in planning resource allocation for future humanitarian missions in low-and middle-income countries. (Surgery 2015;157:850-6.)
Emergency and Essential Surgical Services in Afghanistan: Still a Missing Challenge
World Journal of Surgery, 2010
Background In Afghanistan, the number of surgically amenable injuries related to civil unrest and ongoing conflict or consequent to road traffic accidents, trauma, or pregnancy-related complications is rising and becoming a major cause of death and disability. This study was designed to evaluate availability of basic lifesaving and disability-preventive emergency surgical and anesthesia interventions representing most of the country. Methods Evaluation was performed outside Kabul to represent a cross-section of the country. Data were collected from Afghanistan health facilities, using the WHO Tool for Situation Analysis to Assess Emergency and Essential Surgical Care, covering case volume, travel distances, infrastructures, human resources, supplies, equipment, and interventions characterizing basic trauma, surgery, and anesthesia capacities. Results In 30% of the 17 facilities examined, oxygen supply is limited and irregular; uninterrupted running water is not accessible in 40%; electrical power is not available continuously in 66%. Shortage of equipment and personnel is evident in peripheral health facilities: certified surgeons are present in 63.6% and certified anesthesiologists in 27.2%. Continuous 24 h surgical service is available in 29.4%. Lifesaving procedures are performed in 17–42% of peripheral hospitals; 23.5% are without emergency obstetric service. Conclusions Limited access to surgery is highly remarkable in Afghanistan, with a severe shortage of emergency surgical capacities in provincial and district hospitals, where availability of basic and emergency surgical care is far from satisfactory. A comprehensive approach for strengthening basic surgical capacities at the primary health care level should be introduced.
Prehospital and Disaster Medicine, 2012
Following large-scale disasters and major complex emergencies, especially in resource-poor settings, emergency surgery is practiced by Foreign Medical Teams (FMTs) sent by governmental and non-governmental organizations (NGOs). These surgical experiences have not yielded an appropriate standardized collection of data and reporting to meet standards required by national authorities, the World Health Organization, and the Inter-Agency Standing Committee's Global Health Cluster. Utilizing the 2011 International Data Collection guidelines for surgery initiated by Médecins Sans Frontières, the authors of this paper developed an individual patient-centric form and an International Standard Reporting Template for Surgical Care to record data for victims of a disaster as well as the co-existing burden of surgical disease within the affected community. The data includes surgical patient outcomes and perioperative mortality, along with referrals for rehabilitation, mental health and psych...
Prehospital and Disaster Medicine, 2011
The provision of surgery within humanitarian crises is complex, requiring coordination and cooperation among all stakeholders. During the 2011 Humanitarian Action Summit best practice guidelines were proposed to provide greater accountability and standardization in surgical humanitarian relief efforts. Surgical humanitarian relief planning should occur early and include team selection and preparation, appropriate disaster-specific anticipatory planning, needs assessment, and an awareness of local resources and limitations of cross-cultural project management. Accurate medical record keeping and timely follow-up is important for a transient surgical population. Integration with local health systems is essential and will help facilitate longer term surgical health system strengthening.
World Journal of Surgery, 2011
Background The earthquake that struck Haiti on 12 January 2010 caused significant devastation to both the country and the existing healthcare infrastructure in both urban and rural areas. Most hospital and health care facilities in Port-au-Prince and the surrounding areas were significantly damaged or destroyed. Consequently, large groups of Haitians fled Port-au-Prince for rural areas to seek emergency medical and surgical care. In partnership with the Haitian Ministry of Health, Partners in Health (PIH) and Zanmi Lasante (ZL) have developed and maintained a network of regional and district hospitals in rural Haiti for over twenty-five years. This PIH/ZL system was ideally situated to accommodate the increased need for emergent surgical care in the immediate quake aftermath. The goal of the present study was to provide a crosssectional assessment of surgical need and care delivery across PIH/ZL facilities after the earthquake in Haiti. Methods We conducted a retrospective review of hospital case logs and operative records over the course of three weeks immediately following the earthquake. Results Roughly 3,000 patients were seen at PIH/ZL sites by a combination of Haitian and international surgical teams. During that period 513 emergency surgical cases were logged. Other than wound debridement, the most commonly performed procedure was fixation of long bone fractures, which constituted approximately one third of all surgical procedures. Conclusions There was a significant demand for emergent surgical care after the earthquake in Haiti. The PIH/ ZL hospital system played a critical role in addressing this acutely increased burden of surgical disease, and it allowed for large numbers of Haitians to receive needed surgical services. Our experiences reinforce that access to essential surgery is an essential pillar in public health.
The Role of International Volunteers in the Growth of Surgical Capacity in Post-earthquake Haiti
World Journal of Surgery, 2015
Background The 2010 Haiti earthquake severely strained local healthcare infrastructure. In the wake of this healthcare crisis, international organizations provided volunteer support. Studies demonstrate that this support improved short-term recovery; however, it is unclear how long-term surgical capacity has changed and what role volunteer surgical relief efforts have played. Our goal was to investigate the role of international surgical volunteers in the increase of surgical capacity following the 2010 Haiti earthquake. Methods We retrospectively analyzed the operative reports of 3208 patients at a general, trauma and critical care hospital in Port-au-Prince from June 2010 through December 2013. We collected data on patient demographics and operation subspecialty. Surgeons and anesthesiologists were categorized by subspecialty training and as local healthcare providers or international volunteers. We performed analysis of variance to detect changes in surgical capacity over time and to estimate the role volunteers play in these changes. Results Overall number of monthly operations increased over the 2.5 years post-earthquake. The percentage of orthopedic operations declined while the percentage of other subspecialty operations increased (p = 0.0003). The percentage of operations performed by international volunteer surgeons did not change (p = 0.51); however, the percentage of operations staffed by volunteer anesthesiologists declined (p = 0.058). The percentage of operations performed by matching specialty-and subspecialty-trained international volunteers has not changed (p = 0.54). Conclusions Haitian post-earthquake local and overall surgical capacity has steadily increased, particularly for provision of subspecialty operations. Surgical volunteers have played a consistent role in the recovery of surgical capacity. An increased focus on access to surgical services and resource-allocation for long-term surgical efforts particularly in the realm of subspecialty surgery may lead to full recovery of surgical capacity after a large and devastating natural disaster.