LETTER TO THE EDITOR

Re: Complications in Patients With Spinal Cord Injuries Sustained in an Earthquake in Northern Pakistan. J Spinal Cord Med. 2007;30:313–317.

TO THE EDITOR:

We read with interest the article by Tauqir et al (1). While we agree with most of the content, based upon our experience of management and rehabilitation of 187 cases of spinal cord injury (SCI) in this devastating earthquake (2), we offer the following comments:

1. Rehabilitation medicine is underdeveloped in Pakistan and generally equated with “physiotherapy” alone (2). Because there are no dedicated spinal injury units employing a multidisciplinary-team approach in the management and rehabilitation of these patients, we experienced many avoidable complications.

2. The majority of patients with SCI were received in the hospitals of Rawalpindi and Islamabad; however, apart from the Armed Forces Institute of Rehabilitation Medicine (AFIRM), initially, no rehabilitation specialists were available to facilitate SCI rehabilitation (3).

3. Patients cared for by the physiatrists had fewer complications compared with patients managed in makeshift centers under the care of non-physiatrists (2).

4. Urinary tract infections were the commonest of all secondary complications. We identified the following etiologies: inadequate fluid intake, placement of indwelling catheters before admission at the site of disaster (where clean technique was not used), long-term placement of indwelling catheters, poor perineal hygiene, and reuse of disposable catheters (2).

5. The incidence of pressure ulcers (PU) has been understated. Since our study was prospective over 3 months, the incidence of pressure ulcers (PU) was slightly higher (28.9%) than that reported by Tauqir et al (20%). Six months after the disaster, nearly 75% of patients had developed at least one PU and 2 deaths were attributable to septicemia secondary to PU. Possible etiological factors are lack of knowledge among providers regarding PU prevention, inadequate change of posture, lack of availability of pressure-relief mattresses and cushions in the early phase, and delay in identification of early signs of skin breakdown (2).

6. We observed patients for signs and symptoms suggestive of deep vein thrombosis (DVT) and ordered duplex ultrasound based on clinical suspicion. We confirmed 9 cases of DVT out of the 17 clinically suspected cases for an incidence of DVT of 4.8% (9/187) in our study group (2).

7. The incidence of clinically detectable depression at the end of 3 months post disaster in this study group was only 5.8% (2), which may be explained by timely interventions by psychiatrists and psychologists aided by large numbers of volunteers and social support groups (3).

The Pakistan earthquake on the 8th of October 2005 was a devastating tragedy with long-lasting effects and haunting memories. Some may say that patients with SCI “were the most neglected of all patients in this earthquake” (4), but the medical community was successful to a large extent in managing a large number of SCI casualties because of its collective zeal to deliver its best under the circumstances.