Medical care following earthquakes: Clinical, organizational, and logistic challenges

Abstract

The orthopedic load following earthquakes exceeds that caused by any other disaster. This is due to the large number of musculoskeletal injuries due to falling debris, coupled with the widespread damage to general and medical infrastructure, causing a huge imbalance between surgical needs and the ability to address these needs, necessitating a switch in mindset and operational mode. Clinically, the operational mode will be that of damage control surgery, considering “life before limb” with only lifesaving and limb-saving procedures being performed during the acute phase of the event. Open wounds are treated by thorough debridement, and fixation is performed using plaster casts or external fixation. Open reduction and internal fixation of closed fractures will be deferred until the surge subsides or the patient reaches a fully functional medical facility. Organizational and logistic needs will be addressed considering the “4 S’s”: space, staff, supplies and system. Geographical changes will be necessary in the hospital, shifting activities from damaged structures to safe ones or to open spaces. Field hospitals may be erected on the hospital grounds or on an independent site. Medical staff will be overloaded, especially traumatologists, orthopedic and plastic surgeons, anesthesiologists, and surgical nurses. This can be addressed by the recruitment of supplementary personnel, task shifting, and on-site training. Supplies will be augmented from nonfunctional hospitals and other external sources, and the hospital system will switch to surge mode with appropriate work shifts and emergency standard operation procedures. All this necessitates preplanning, preparing, and drilling in order to mitigate the effects of this disastrous event.

Highlights

• All disasters are characterized by an extreme imbalance between the needs and the capabilities to fill these needs.

• Earthquakes cause more injuries than any other disaster.

• Orthopedic care will shift from early total care to damage control surgery. Logistic and organizational changes must be made in hospital operation in order to maximize capabilities.

Introduction

The recent earthquake that struck Turkey and Syria caused massive destruction, with more than 25 million people affected, 70 000 killed, and 120 000 injured.¹ Occurring only 24 years after the 1999 Izmit Earthquake, it highlighted yet again the destructive power of these events and the resultant huge toll in life and injuries. It was a reminder of the need for planning and preparation for such events and the ability to operate in a mode that is very different from our mode of operation in routine times. This review will address the effects and needs following natural disasters, specifically those following earthquakes, and the unique clinical, organizational, and logistic aspects of coping with these situations.

A mass casualty event (MCE) can be defined in many ways and is dependent on the magnitude of the event and the resources available to cope with it. A useful definition, therefore, is an event in which the condition of 1 patient affects the treatment of other patients. A disaster can be considered a mega MCE that overwhelms local treatment capacity, causes loss of autonomy, and necessitates external assistance. Disasters can be caused by natural causes or man-made events. The current review will address the challenges and solutions during natural disasters. These include geologic events like earthquakes, volcano eruptions and tsunamis, meteorological events—storms, floods, droughts, and extreme temperatures and biologic events—pests, and pandemics. In addition, we may encounter “Natech” events when natural disasters cause secondary technical disasters, such as those that occurred in Fukoshima when a tsunami resulted in a nuclear leak. The needs of the affected population are large and wide, including shelter, food, water, sanitation, and hygiene (WASH), security (both physical and emotional), search and rescue (SAR), burying the dead, and medical care for the wounded and sick. Each type of disaster has its unique characteristics regarding mortality, morbidity, and treatment needs and capabilities.² However, all these events are characterized by a severe imbalance between medical needs and the capacity to fill these needs. Therefore, the approach to planning and executing an operational plan should be an “All Hazards” approach combined with an understanding of the unique characteristics of each event. The effects of each of these events should be analyzed according to the resultant environmental and infrastructural damage with resultant logistic needs and the effect on the health system, including mortality and morbidity with the resultant medical and surgical needs.

Tsunamis

These cause huge environmental damage to both general and medical infrastructure, with huge resultant logistical needs. They can also cause a large number of deaths, as witnessed in the Sumatra–Andaman earthquake in December 2004 with the resultant Boxing Day Tsunami, which affected a large area including 14 countries and resulted in over 200 000 deaths.³ However, although some injuries are caused by the event, including traumatic injuries and near drowning, the medical needs following a tsunami are secondary, with the main needs of the affected population being shelter, food, and WASH, as well as psychosocial and community rehabilitation.

Storms and floods

These occur with increasing frequency and intensity in recent years due to climate changes, and similar to tsunamis, they cause severe environmental damage and may affect wide areas; however, meteorological monitoring enables early warning of their arrival and evacuation of populations from the affected areas and the medical and surgical needs are less significant than the needs for shelter and food.

Volcanic eruptions

These may cause severe environmental damage, burying whole communities under the lava flow. They also cause a large number of deaths and injuries in the affected areas due to burns, inhalation injuries and crush injuries under the buried buildings. However, the effects of the eruption are usually in a rather limited area surrounding the volcano. In addition, after the initial event, the following eruptions and lava flows are at a time line which enables evacuation and the local inhabitants often have experience from previous eruptions.

Outbreaks and pandemics

These may be a cause of major mortality and morbidity as well as community disruption, as witnessed in the recent coronavirus disease 2019 pandemic; however, these will not be addressed in the current review.

Earthquakes

Of all natural disasters, earthquakes cause more musculoskeletal injuries as well as an imbalance between needs and capabilities than any other event.^4,5 The reasons for this include:

1. The amount of energy released is greater than any other disaster.

2. Most of the energy is mechanical energy, resulting in a large number of fractures and soft tissue injuries.

3. An earthquake, more than any other event, is a sudden-onset disaster. As opposed to other types of disasters which have forewarning signs enabling preparation and evacuation of the population, at present there is no reliable warning mechanism before the earthquake strikes, and the population will always be found unprepared.

4. In contrast to other disasters in which the damaging effects are spread over many hours, days, or months, in an earthquake all the damage is caused within several minutes, causing a huge surge in the number of patients flooding the medical system.

Injury mechanisms and causes of morbidity

1. Most injuries are caused by falling debris from destroyed buildings, causing fractures and soft tissue injuries, as well as crush injuries due to entrapment under the fallen debris.

2. Fall injuries will be caused by victims falling from higher stories of collapsing buildings as well as jumping from heights while attempting to escape from these buildings. During the aftershocks, people terrorized by the previous experience may jump from the higher floors in order to escape. In addition, many minor injuries will be caused by people tripping and falling while running for safety.

3. Dust inhalation injuries are a major cause of morbidity due to the thick clouds of dust in the air from the fallen buildings.

4. Burns are common due to the affected population having lost their homes, living on the street, and cooking on improvised utensils.

5. Poor water quality and sanitary conditions may cause outbreaks of infectious diseases.

6. The breakdown of routine medical services will cause a surge in morbidity due to noncommunicable diseases as well as the results of delaying elective surgery.

There are multiple factors that will affect the number and severity of injuries:

1. The seismic parameters of the earthquake—magnitude and depth of the epicenter.

2. The time of occurrence: earthquakes occurring at night while the population is sleeping indoors causing an increased number of casualties.

3. The area affected: An earthquake occurring in a densely populated urban area will obviously cause a significantly larger number of casualties and severe injuries than an earthquake centered in a rural, sparsely populated area. However, when remote villages are affected, evacuation from the destruction site poses significant problems, especially in mountainous areas with destroyed or blocked roads necessitating clearing or repair. In these situations, airborne evacuation of the victims by helicopters may be the only solution; however, helicopters will be a limited resource.

4. The type and quality of buildings in the affected area are major affecting factors. The collapse of multiple storied building will obviously cause many more injuries than that of a single-story building. In addition, the quality and strength of the structures as well as the existence and enforcement of building regulations can greatly decrease the number of casualties and the severity of injuries.

5. Escape of hazardous materials (HAZMAT) can cause a large number of injuries introducing yet another significant health threat.

6. The local capacities regarding SAR, evacuation and the strength of the local emergency system, the medical system, and the local emergency medical teams (EMT).

7. The arrival of foreign SAR teams and EMTs.

Logistic effects

The massive environmental damage caused by the earthquake will have major logistic consequences, both increasing morbidity and affecting the capability of the health system to deliver care.

1. The destruction of general infrastructure will cause road blockages and electrical and communication systems may be nonfunctional. All these will affect the capability of the SAR teams to reach the injured and will inhibit the ability of the medical teams to deliver care.

2. The water system and the sewage system may be damaged, and garbage will accumulate. This may cause infectious outbreaks.

3. Medical infrastructures in the hospitals will be partially or completely destroyed, thus decreasing the capacities and capabilities of the medical system in a situation in which these capabilities should surge.

All these factors will increase morbidity due to the delay in delivering treatment to the patients, adding wound infections to the already severe injury patterns.

Postearthquake Phases

The timeline following the earthquake shows varying needs according to the time elapsed from the event.⁶

Phase 1 (0-48 hours from the event): At this phase victims suffering life-threatening thoracic, abdominal, and head injuries may be salvageable; however, international SAR teams have not yet arrived and the local medical system is only partially functional. The number of lives saved will depend on local capabilities, and the majority of survivors will be extricated from the rubble by family members, neighbors, and local SAR teams. While in the first 24 hours after the earthquake, the survival rate will be around 90%, by 48 hours it will fall to 50%, dropping to 20% at 72 hours after the event.⁷

Phase 2 (day 3-day 15): This phase will witness the arrival of multiple SARs and EMTs. However, the number of live survivors extricated will have decreased. Most patients with direct life-threatening injuries will have been treated or will have perished, and the main morbidities encountered will be treatable musculoskeletal injuries; however, patients will still die due to crush injuries as well as sepsis, as most wounds will be contaminated and infected due to the long time lapse between injury and treatment. The patient load will also include medical emergencies unrelated to the earthquake as well as patients seeking routine care, which has been suspended due to the overload of the medical system, and by day 10, less than 50% of the patients treated will be due to earthquake-related injuries.

Phase 3 (week 3-6): During this phase, the workload will include continued treatment of the earthquake injuries—definitive fracture treatment, soft tissue coverage, and early rehabilitation—with a gradual shift back to predominant routine medical care. The workload will still be significantly increased as many of the foreign teams will depart and the local system will still be only partially functional.

Phase 4 (3-12 months): This is the rehabilitation stage for both the patients, the medical system, and the community. Long-term limb reconstruction will continue coupled with rehabilitation, medical facilities will be repaired and reconstructed, families will rebuild their homes or relocate to different areas, and community life will gradually get back to normal although the long-term effects of the earthquake will continue to be felt for years to come.

Hospital operation following the earthquake

Due to all of the abovementioned causes, the mode of operation will necessitate “changing the diskette” in all aspects of care delivery, shifting from a routine mode to a mode of “working with shortages.” The shortages will be in all aspects of hospital operations and are known as

“The 4 S’s”: Space, Staff, Stuff (Supplies), and System.

Space: The main shortages will be in the emergency department, the hospitalization wards, the operating room (OR) and sterile surgical environment, the recovery room, and the intensive care unit. In addition, essential auxiliary services such as imaging, laboratory, and blood bank may be damaged.

Staff: Medical personnel may be killed or injured during the earthquake; in addition, we will witness a further reduction in available staff as they will be at home searching for and caring for their families. Specific shortages will be found in traumatologists, orthopedic and plastic surgeons, anesthesiologists, and OR nurses, as well as personnel familiar with treating pediatric patients.

Stuff/supplies: Surgical equipment, which may be adequate during routine times, will be in extreme shortage. This will include orthopedic fixation hardware, power drills, C-arm fluoroscopy machines, and steriliza­tion equipment. All these will be bottlenecks in the surgical flow. Disposables—dressing and casting materials, sheets, gowns, and gloves—will also be in short supply. Equipment designed for pediatric patients may be scarce in hospitals not treating children routinely.

System: The whole organizational system of the hospital during routine times will be inadequate to cope with the surge situation and will have to be adapted to the new operational mode.

Solutions

Space

Geographical shifts will be necessary, establishing treatment areas in alternative sites both within the surviving hospital building after approval by the engineering teams as well as in open spaces on the hospital grounds. These areas will require logistical adaptations, including electrical power, water supply, communication, and medical gases. OR capabilities can be increased by placing 2 operating beds in the same room, and minor surgical procedures can be performed in the outpatient clinics and in the wards. Treatment areas can be established off the hospital grounds to treat minor injuries and acute stress disorders, thus reducing the load within the hospital. A separate enclave should be established for the treatment of expectant patients with no chance of survival, enabling them to end their lives in dignity and with minimal suffering as well as with accompanying families, while decreasing the load on the acute care wards.

EMTs can establish their field hospital on the grounds of the fixed hospital, combining forces and complementing the capabilities of both facilities.⁸

Staff

Task shifting should be performed, transferring the medical staff from medical and ambulatory departments to the emergency room, out patient clinic, and surgical wards. On-site training should be performed to improve their skills in caring for surgical patients. All medical professionals in the community should be mobilized, including those employed in nonfunctional hospitals, retired personnel, and volunteers. However, care has to be taken to examine the qualifications and capabilities of these external personnel in order to avoid inappropriate care. Operating on 2 adjacent beds in the same OR will enable 1 anesthesiologist and circulating nurse to serve both tables.

Stuff/supplies

All available equipment within the hospital should be utilized. Supplemental equipment can be procured from damaged, nonfunctional hospitals. Additional equipment can be received from hospitals outside the disaster zone, from neighboring countries, and from international organizations. Specialized equipment can be supplemented by nonmedical hardware such as power drills. This will necessitate adapting surgical draping and techniques in order to maximize sterility.

System

Adaptations will include changing standard operational procedures to surge mode, merging departments and opening new ones, changing work shift schedules (usually to 12-hour shifts), constructing support mechanisms for employees and their families, manning a command and control center, and establishing coordination systems within the hospital as well as with referral facilities, emergency and aid organizations, local health authorities, and international organizations such as the World Health Organization (WHO).

Surgical care

Similarly to all other aspects of operation in a disaster environment, the approach to surgical care requires a change in mindset. In routine times in a fully equipped hospital, the approach would be early total care, and in a disaster setting, operating in an overwhelmed hospital and medical system or a field hospital with limited resources, the approach to surgical care changes to a damage control surgery (DCS) approach. This concept, which was initially conceived for the treatment of a single polytrauma patient, is applied along the same principles in the mass casualty and disaster scenarios. However, if in routine times the rationale for this approach is to maximize survivability of the single polytraumatized patient, in mass casualty and disaster scenarios the rationale is to maximize utilization of the limited resources and do the greatest good for the greatest number, realizing we cannot do everything for everyone. This will necessitate a shift in decision-making in all aspects of care, including surgical indications, procedure selection, surgical techniques, and occasionally even ethical considerations. In addition, as surgery will often be performed in suboptimal conditions, either in an adapted structure or a field hospital with compromised sterility and limited instrumentation, surgical indications and methods will have to be adapted to this environment.⁹

The principles of DCS include:

1. Triage: Patients will be prioritized for treatment according to the severity of their condition, their survivability, and the resources available to treat their specific injuries.

2. Life over limb: prioritizing lifesaving even at the risk of losing limbs.

3. Performing only lifesaving and limb-saving procedures with other procedures being deferred either to a time when the surge declines or to a facility outside the disaster zone.

4. Limited surgical time: Procedures taking more than ~1.5 hours should be avoided in order to maximize patient flow in the OR and enable treatment of as many patients as possible in the shortest time.

5. Analgesia and anesthesia will be performed preferably using local or regional methods or conscious sedation in order to minimize recovery room time.

Orthopedic care^{10 ,1 1}

The implications of the above principles will affect both the decision-making and the surgical techniques of orthopedic care as follows:

1. Limb salvage vs. amputation: This decision, which is a difficult one even in routine times, is even more difficult in a disaster setting as multiple additional factors come into consideration, some of them unknown. The multiple published scoring systems designed to aid in this decision are unapplicable in the disaster setting as they are based on the results of treatment in major referral centers in developed countries in routine times with abundant surgical resources, rehabilitation facilities, and social support systems, all of which are unavailable in the disaster setting in a low-resource environment. Cultural factors should also be considered, as the attitude to amputation may vary in different populations. Systemic indications for amputation include uncontrollable life-threatening infection, crush syndrome with systemic inflammatory response syndrome , multiorgan failure, and preexisting comorbidities affecting the patient’s capability to survive multiple procedures or the limb’s survivability. Limb-related indications include vascular damage with unavailable repair capabilities, near amputation with unavailable reimplantation capabilities, and massively traumatized limbs “beyond classification.”

2. Surgical priorities in salvageable limbs are:

   1. Limb reperfusion—restoring systemic circulation and local vascular repair or shunting.

   2. Fasciotomy for acute compartment syndrome, although most patients will present >24 hours from injury with a chronic compartment syndrome in which fasciotomy is contraindicated.

   3. Wound debridement is the mainstay of treatment in this environment, as the nature of the injuries will cause extensive tissue damage, and the delay in reaching care will cause most wounds to be infected. Debridement will include removal of all necrotic and infected tissues and contaminants. Bone without periosteal attachment should be discarded. Copious low-pressure washout should be performed using saline solution, and if limited, tap water may be used. Except for minimally clean wounds, primary closure should never be performed, and bone should be covered if possible by temporary soft tissue coverage. Debridement should be repeated at 48-72-hour intervals until a clean wound bed with viable soft tissue is attained. Dressing should be performed with soft, dry, gauze, and negative-pressure dressing may be utilized.

   4. Bone coverage in case of soft tissue loss may be achieved by local flaps or bone shortening.

   5. Skin closure or coverage should be performed only when the wound is clean using primary closure, secondary intent, or split-thickness skin graft.

   6. Fracture reduction is performed with the main goal being proper limb alignment, which will be assessed clinically if C-arm fluoroscopy is unavailable. Precise reduction can be achieved during secondary procedures.

   7. Fixation is performed using either plaster slabs or circular casts with sufficient padding and windowing for wound care if needed. Surgical fixation is performed by external fixation. Closed fractures will always be treated by closed methods. Open reduction and internal fixation are contraindicated due to limited sterility, and definitive fracture care will be deferred until a safe surgical environment is available and the surge subsides.

Funding Statement

The author declared that this study has received no financial support.