Table 2.

Select Clinical Scenarios and Challenges in Humanitarian Settings Based on the Authors’ Personal Experiences in Various Humanitarian Settings

Clinical Scenarios	Context-Specific Challenges in Humanitarian Settings
Trauma and other conditions requiring resuscitation	Airway
	• Limited advanced airway equipment should not preclude basic airway management. Contrary to conventional teachings regarding the need to intubate patients with low GCS, the placement of an oral airway, oxygen, positioning, and suctioning can, at times, be sufficient to manage a patient successfully
	Breathing
	• Reliance on history and clinical examination if imaging modalities not available (e.g., pneumonia vs. pulmonary edema)
	• Lack of wall suction for chest tubes and pleural drains
	• Trial of bag-mask ventilation in lieu of NIV for conditions that benefit from NIV
	• Manual bagging with endotracheal tube in situ in lieu of mechanical ventilation because of limited or lack of ventilators
	• Need for prolonged manual bagging until recovery if ventilator not available for organophosphate toxicity (consideration of teaching family members bagging technique)
	Circulation
	• Lack of central venous lines and ensuring safe administration of vasoactive medications with peripheral IV cannulas
	• Insertion of multiple peripheral IV cannulas in series into the same vein in patients with poor venous access options in lieu of a multilumen central venous line when multiple medication infusions are required
	• Use of nebulized salbutamol for temporary management of symptomatic bradycardia when atropine or other vasoactive medications are not available
	• Limited availability of blood products and predominate use of whole blood
	• Limited reversal of coagulopathy from lack of fresh blood
	• Limited systems/processes in place for immediate blood transfusions and the need to anticipate in advance if transfusions will be required (e.g., need to call in donors, who are usually patient relatives, to obtain blood)
	• Limited IV line warmers and blood warmers
	• Reliance on urine output and mental status as markers of shock
	Disability (neurological)
	• Language barrier can make neurologic assessment challenging
	• Incomplete neurological assessments with lack of assessment of GCS, pupils, eye movements, gaze preference, cranial nerves, presence of motor and sensory levels
	• Limited imaging, monitoring, and advanced interventions for brain injuries
	• Limited stabilization in the field, assessment and monitoring skills, imaging, monitoring, and advanced interventions for spinal cord injuries
	• CT imaging guidelines based on prognosis and not necessarily severity
	• Lack of postoperative neuro–intensive care capabilities preclude interventions, resulting in referral of patients to other facilities if available
	Exposure (and other organ systems)
	• Reliance on physical examination with limited blood tests and imaging modalities
	• Casting/splinting and external fixation predominates with lack of resources for internal fixation for orthopedic fracture management
	• Limited burn care resources and treatment capabilities for thermal burns and electrical injuries
	• Considerations for special wound care management (e.g., rabies immunoglobulin, tetanus immunoglobulin, snake antivenom)
	• Lack of referral pathways, prehospital clinicians, and medically staffed ambulances
	Multiple causalities
	• Frequent occurrence of multiple-causality events or incidents alongside day-to-day operations using preestablished triage and disaster plans
	• Patients or family members may assist in procedures (e.g., hold chest tube after it is inserted while clinician sutures it to the chest)
	• Extubate stable open-abdomen patients (pragmatic to the situation)
Perioperative and anesthesia	• Lack of complex ventilators and anesthetic machines for inhalational anesthesia
	• Use of alternative (potentially unfamiliar) anesthesia delivery systems, such as draw-over anesthetic circuits
	• Unreliable supply of gases (either piped or bottled)
	• Unreliable supply of electricity
	• Predominate use of spinal anesthesia
	• Predominate use of ketamine and basic airway management
	• Anesthetic agents may differ significantly from high-income countries (e.g., halothane)
	• Limited anesthesia specialists and training of nonphysician anesthesia clinical staff
	• Lack of ventilators/lack of ICU results in overreliance of postanesthesia recovery room or the emergency department for postoperative ventilated patients who could not be extubated (or kept in the operating theater)
	• Common cultural low regard for the importance of postanesthesia recovery room
	• High proportion of clinically unwell children presenting for surgery; may strain the clinician (if unfamiliar with pediatrics) and the resources of equipment
Obstetrics	• Unknown antenatal history and poor antenatal care
	• High parity because of poor access to family planning (or due to cultural norms)
	• Complications of unsafe abortions
	• Uterine ruptures from oxytocin misuse and abuse
	• Postpartum hemorrhage often presents late (e.g., after home delivery) and in hemorrhagic shock, with limited or short supply of medical therapies (e.g., tranexamic acid or blood transfusion)
	• Populations with high prevalence of severe preeclampsia/eclampsia (seizures are seen as a spiritual event rather than a medical problem in some cultures, which results in late presentation after hours of uncontrolled hypertension and seizures possibly leading to an intracerebral hemorrhage)
	• Lack of access and understanding for preventive low-dose aspirin after severe preeclampsia or eclampsia, which could significantly reduce the risk of complications of future pregnancies
	• Preference for vaginal delivery to avoid complications after cesarean section in future pregnancies
	• Late presentation or referral of patients in obstructed labor with resulting difficult cesarean sections and risk of obstetric fistula
	• High incidence of female genital mutilation in some populations
Pediatrics	• Clinicians need to be comfortable managing both adults and children, as pediatric specialists may not always be available
	• A large number of patients presenting to hospital are children (e.g., traumatic injuries, burns, infections)
	• Large number of critically ill neonates presenting after home deliveries requiring resuscitation
	• Frequent cases of malnutrition and use of ready-to-use therapeutic foods
Infections	• Endemic considerations: tuberculosis, HIV, malaria, typhoid, dengue, cholera, viral hemorrhagic fevers
	• Minimal infection, prevention, control resources and limited ability for isolation rooms
	• Neonatal tetanus from cutting umbilical cord with dirty objects
	• Measles due to lack of immunization

Definition of abbreviations: CT = computed tomography; GCS = Glasgow Coma Scale; NIV = noninvasive ventilation.