Abstract
The numbers of people affected by large-scale disasters has increased in recent decades. Disasters produce a huge burden of surgical morbidity at a time when the affected country is least able to respond. For this reason an international disaster response is often required. For many years this disaster response was not coordinated. The response consisted of what was available not what was needed and standards of care varied widely producing a healthcare lottery for the affected population. In recent years the World Health organisation has initiated the Emergency Medical Team programme to coordinate the response to disasters and set minimum standards for responding teams. Anaesthetists have a key role to play in Level 2 Surgical Field Hospitals. The disaster context produces a number of logistical challenges that directly impact on the anaesthetist requiring adaptation of anaesthetic techniques from their everyday practice. The context in which they will be working and the wider scope of practice that will be expected from them in the field mandates that deploying anaesthetists should be trained for disaster response. There have been significant improvements in recent years in the speed of response, equipment availability, coordination and training for disasters. Future challenges include increasing local disaster response capacity, agreeing international standards for training and improving data collection to allow for future research and improvement in disaster response. The goal of this review article is to provide an understanding of the disaster context and what logistical challenges it provides. There has been a move during the last decade from a globally uncoordinated, unregulated response, with no consensus on standards, to a globally coordinated response through the World Health Organisation (WHO). A classification system for responding Emergency Medical Teams (EMTs) and a set of agreed minimum standards has been defined. This review outlines the scope of the role of the anaesthetist in a Level 2 field hospital and some of the challenges that this scope and context present. It focuses mainly on natural disasters, but also outline some of the differences encountered in responding to other global disasters such as conflict and infectious outbreaks, and concludes with some of the challenges for the future.
The disaster context
The World Health Organisation (WHO) defines a disaster as “A sudden event causing severe destruction of infrastructure, people and the economy and which overwhelms the resources of that country, region or community.”1 These disasters may be caused by natural events such as earthquakes, tsunamis and disease epidemics or man-made disasters such as war and industrial accidents. Natural disasters have in recent decades increased in frequency.2 This may be partly because of an increased rate of reporting but there is clear evidence that global flood events have increased in recent years.3 Whilst the rate of earthquake events appear to be unchanged the numbers of those affected has risen as a result of their occurring in high population density areas.2
Disasters lead to a number of logistical challenges. The local government may be severely affected itself by the disaster, as was the case after the 2010 Haiti earthquake. As a result the local organisations that would normally coordinate any disaster response may not be operational. The infrastructure is usually badly damaged, either because of physical destruction or as a result of the absence of the workforce; and so water, electricity, food and transport may all be absent or at best in short supply. In addition, the local healthcare structures and staff are also severely affected;4,5 so just at the point where there is a massive surge in healthcare needs there is also a large reduction in healthcare capacity (Fig. 1).
Trinite hospital, the MSF trauma centre destroyed in the 2010 Haiti earthquake.
Whilst the logistical challenges across disasters are fairly consistent the medical challenges vary widely. Different types of disaster have different patterns of mortality and morbidity. As anaesthetists the disaster that tends to represent our “worst case scenario” is the urban earthquake. Urban earthquakes produce a high ratio of injuries to deaths (three injuries:one death) compared with flooding and tsunamis (one injury:nine deaths). This is because in flooding type disasters anyone with significant injuries is likely to drown.6,7 The type of injury in an earthquake is also more likely to require surgical and therefore anaesthetic care. Typically, earthquakes produce severe blunt trauma with crush injuries, wound infections and burns, often requiring multiple surgical procedures.8,9 After tsunamis and flood events patients are more likely to present with near drowning, pneumonia, hypothermia, and infected soft tissue injuries.10,11
Different disaster types also follow different timelines in terms of presentation to hospital. In a “typical” natural disaster there will be an initial peak of injuries directly related to the event. These may present over several days as a result of the difficulties of getting to a hospital. There may then be a second peak of admissions after two to three weeks “the second emergency,” when medical teams who only have resources for a few weeks deployment go home and their patients must be transferred. In conflict situations by contrast there tend to be smaller recurrent peaks of casualties (Fig. 2).12 In both situations over weeks to months there is a gradual increase in presentations of exacerbation of chronic health conditions reflecting breakdown in primary care and difficulty accessing medicines; an increase in burns because of displaced populations using kerosene lamps and stoves; an increase in infectious diseases as a result of cramped poor living conditions in displaced persons camps; and an increase in obstetric emergencies reflecting lack of access to antenatal care. For the duration of the emergency period there is not usually capacity for scheduled cancer and elective surgery.13–15
Conceptual graph of numbers of patients presenting to hospital over time in conflict vs natural disaster.
Organisation of the international disaster response
Until recent years there was no coordinated, organised global medical response to global disasters. Whilst some of the large international non-governmental organisations such as Medecins sans Frontieres (MSF) or the International Committee of the Red Cross (ICRC) individually had a very high quality organised response, these were not integrated with other responders. Integration often relied on personalities on the ground rather than at the headquarters level and usually only after deployment of teams. In recent years social media and 24 h news has led to very rapid and extensive reporting of disasters. One effect of this has been a raised awareness in the global medical population of disasters as they happen, and an understandable desire to do something to help. This combination of widespread media coverage and a large healthcare population wishing to help came to a head in the 2010 Haitian earthquake. Large numbers of medical teams responded, at its height around 40 medical teams a day were registering with the United Nations on arrival in Haiti, with more than 300 in place by the end of the second week. Other medical teams, in contrast, did not know to or chose not to register. These teams were extremely variable in terms of experience and training in disaster response. Many teams performed well but lack of coordination with other providers led to duplication of services and wasted resources. Some teams arrived without the necessary logistical support, causing a drain on already stretched local resources, and eventually left without ever treating any patients. In a few cases teams carried out inappropriate procedures, that they were not qualified to do in their own countries, with inadequate anaesthesia and analgesia, on the grounds that it was the best that could be done in a disaster. The local population was left with a healthcare “lottery” with very different standards of care depending on which team they presented to. The population were very aware of this and if able to “shopped” around visiting different teams. This led to problems of delayed treatment, discontinuity of care and wasted resources.16
After Haiti there was a general call from the international medical community for an improvement in standards and coordination for disaster response.17 This has led to the production by the WHO of the Emergency Medical Team (EMT) Classification and Programme. This programme lays down minimum standards for emergency medical teams responding to a disaster. Teams are categorised into three levels: Level 1 - outpatient emergency care; Level 2 - inpatient surgical emergency care; and Level 3 - inpatient referral hospital with ICU facilities.18 The standards lay down the technical and logistical capabilities that teams must possess at each level, the speed with which they can be deployed and the human resources required. The majority of anaesthetists will find themselves deployed in Level 2 type field hospitals (Table 1). A Level 2 field hospital must be capable of being fully independent with a structure to work in (generally tented), generators and the capability to provide its own water and food. Technically it must provide emergency medical, surgical and obstetric care with the ability to stabilise more serious patients for transfer to referral hospitals with ICU facilities.
Minimum standards for Level 2 emergency medical team, inpatient surgical emergency care: inpatient acute care, general and obstetric surgery for trauma and other major conditions18
| Medical | Organisational |
|---|---|
| Surgical triage, assessment and advanced life support | Use existing or deployable facility |
| Definitive wound and basic fracture management | Clean operating theatre environment |
| Damage control surgery | Care appropriate to context and changing burden of disease |
| Emergency general and obstetric surgery | Multidisciplinary team experienced in working in resource scarce settings |
| Inpatient care for non trauma emergencies | One operating theatre with one operating room to 20 inpatient beds |
| Basic anaesthesia, x-ray, blood transfusion, lab and rehab services | Seven major or 15 minor operations/day |
| Acceptance and referral service | 24 h services |
| Medical | Organisational |
|---|---|
| Surgical triage, assessment and advanced life support | Use existing or deployable facility |
| Definitive wound and basic fracture management | Clean operating theatre environment |
| Damage control surgery | Care appropriate to context and changing burden of disease |
| Emergency general and obstetric surgery | Multidisciplinary team experienced in working in resource scarce settings |
| Inpatient care for non trauma emergencies | One operating theatre with one operating room to 20 inpatient beds |
| Basic anaesthesia, x-ray, blood transfusion, lab and rehab services | Seven major or 15 minor operations/day |
| Acceptance and referral service | 24 h services |
Minimum standards for Level 2 emergency medical team, inpatient surgical emergency care: inpatient acute care, general and obstetric surgery for trauma and other major conditions18
| Medical | Organisational |
|---|---|
| Surgical triage, assessment and advanced life support | Use existing or deployable facility |
| Definitive wound and basic fracture management | Clean operating theatre environment |
| Damage control surgery | Care appropriate to context and changing burden of disease |
| Emergency general and obstetric surgery | Multidisciplinary team experienced in working in resource scarce settings |
| Inpatient care for non trauma emergencies | One operating theatre with one operating room to 20 inpatient beds |
| Basic anaesthesia, x-ray, blood transfusion, lab and rehab services | Seven major or 15 minor operations/day |
| Acceptance and referral service | 24 h services |
| Medical | Organisational |
|---|---|
| Surgical triage, assessment and advanced life support | Use existing or deployable facility |
| Definitive wound and basic fracture management | Clean operating theatre environment |
| Damage control surgery | Care appropriate to context and changing burden of disease |
| Emergency general and obstetric surgery | Multidisciplinary team experienced in working in resource scarce settings |
| Inpatient care for non trauma emergencies | One operating theatre with one operating room to 20 inpatient beds |
| Basic anaesthesia, x-ray, blood transfusion, lab and rehab services | Seven major or 15 minor operations/day |
| Acceptance and referral service | 24 h services |
In addition to the classification and standards the programme holds an international register of teams that have been inspected and accredited to these standards with the aim of guaranteeing a minimum set standard of care. Governments affected by a disaster now contact the WHO with a request for what number and types of team they require. The teams from the register are then invited to respond to the disaster with the aim of better matching the response to the needs. In the field, the WHO works closely with the local ministry of health to task teams to the most appropriate geographical areas working in coordination with existing local healthcare structures and staff. The aim is to reduce duplication of effort and wasted resources and provide better continuity of care for patients once the international teams leave. Teams who attend a disaster who have not been invited are likely to find themselves turned away on arrival at the airport.
Local disaster response
In Figure 3 we can see how quickly (and how many) teams were able to arrive in the field for some of the major disasters of the last few years. Whilst the international response has become more coordinated and faster into the field over recent years it can be seen Figure 3 that very few teams can arrive in under 24 h and most take at least 48 h to arrive, but they may then take several more days to become operational. This is clearly too late for the majority of life-threatening injuries and these teams are arriving mainly at the phase of limb salvage and reduction of long-term morbidity. This delay also means that even for non life-threatening injuries timely debridement of dirty wounds and open fractures is not possible with worse long-term outcomes. For at least the first 48 h many local staff are effectively on their own. There are three main options open to them. First, they may be able to salvage equipment and work in a limited way to provide life-saving surgery. This was the initial approach that the MSF trauma hospital in Haiti had to take for the first 48 h but sterility and capacity were far from ideal (Fig. 4). Secondly, if areas of the country have not been affected it may be possible to rapidly transfer a large number of patients out of the affected region: this happened to a large extent after the 2015 Nepal earthquake. Kathmandu remained mainly functional and so large numbers of patients could be transferred quickly to the capital from the worst affected regions. Finally, in large countries such as India and China there may be capacity for local disaster response teams to deploy. This is the ideal situation as they can arrive faster than an international team, generally speak the same language and understand the existing healthcare system providing better exit planning and continuity of care.19 Whether the emergency medical team is local or international the goal is that they will be working to the same standards and have the same level of training.
Emergency medical teams registering each day during recent disasters. From: WHO EMT initiative Jan 2017. Available from https://extranet.who.int/emt/sites/default/files/EMT_Updatednews_19.01.2017.pdf (accessed 21 September 2017).
Makeshift operating theatre in use for the first few days after the Haiti earthquake.
The role of the anaesthetist
The EMT classification and standards gives clear guidance on human resources for deploying EMTs. Any organisation deploying a Level 2 field hospital must provide at least one medically qualified anaesthetist. Some previous teams have deployed with no anaesthetist assuming that they would have access to a local anaesthetist, or deployed only with nurse anaesthetists leaving gaps in perioperative and critical care management for patients. The classification and standards have made it clear what services should be provided by an EMT and therefore what roles, knowledge and skill sets will be required from the anaesthesia team. These include:
Anaesthesia set up
The anaesthetist in the first team to deploy must be fully trained and prepared to set up for anaesthesia and/or resuscitation for the operating theatre, delivery room, recovery room, high dependency area and emergency room. This may include building furniture, and setting up oxygen concentrators, suction, airway equipment and anaesthesia draw-over systems. They will need to stock all the areas with disposable equipment, drugs and paperwork and ensure ready access to all necessary protocols such as antibiotic prophylaxis, thromboprophylaxis and the WHO checklist (Fig. 5).
Typical Level 2 operating theatre deployed to the Nepal earthquake.
Provision of anaesthesia
One challenge for deploying anaesthetists is the range of specialties across which they will have to work. For many there will be at least one area that does not form part of their daily routine practice. Anaesthetists on the team need to be able to manage the perioperative care and provision of anaesthesia for trauma patients including high dependency unit level care for tetanus and crush injury; obstetric emergencies and neonatal resuscitation; general surgical emergencies; burns and very importantly paediatrics which may make up to 25% of cases. They also need to be prepared to manage acute and chronic pain issues on the wards, particularly those arising from neuropathic pain as nerve injuries are extremely common especially in earthquakes16 and conflicts.
There are also a number of technical challenges for the deploying anaesthetist caused by the context in which they are working:
Oxygen and inhalation anaesthesia
One challenge is lack of access to compressed gases, – specifically oxygen. Oxygen cylinders are very heavy and difficult to transport so it is not practical for teams to take oxygen with them. Even if cylinders are available refilling them is not an option. In most disasters oxygen plants are no longer operational or accessible and, in the case of conflict, driving full oxygen cylinders around is very dangerous. For this reason EMTs rely on oxygen concentrators. These are very reliable but require an electricity supply and produce oxygen at a pressure of just over one bar. This pressure is not sufficient for our familiar Boyles type anaesthetic machines and so if a team wishes to provide inhalation anaesthesia it is necessary to use draw-over anaesthesia systems. Drawover systems have a number of advantages in this context: they are small and easy to transport, they continue to work when the electricity fails, they are very economical in oxygen usage (1 l min−1 provides an FIO2 of 0.3), it is not possible to give a hypoxic mixture so inspired oxygen monitoring is less vital, and they are non-rebreathing circuits so agent monitoring is not essential. However, most anaesthetists in their daily practice will have never set them up or used them so some training pre-deployment is required.
I.V. Anaesthesia
Teams may wish to avoid inhalation anaesthesia altogether and rely on total i.v. anaesthesia using either propofol or ketamine. Most anaesthetists from high resource settings are very familiar with giving propofol total i.v. anaesthesia (TIVA). Unfortunately, propofol TIVA also has a number of disadvantages in this context. Propofol anaesthetics require quite a large volume of propofol that must be transported to the disaster zone, contrasted with ketamine which comes in high strength ampoules one of which will be sufficient for several anaesthetics. Ketamine is also much more forgiving of extremes of temperature during transport and storage compared with propofol. Propofol causes respiratory depression and apnoea is common in contrast to ketamine. This becomes important when the electricity and therefore oxygen supply is unreliable. In addition, teams frequently work alongside local anaesthetic nurses and officers who have a lot of experience monitoring people receiving ketamine anaesthesia but not propofol and do not always have the skills to reliably recognise and manage airway obstruction, hypoventilation and apnoea. The same points apply to the recovery room. Finally, ketamine also provides good postoperative analgesia whereas propofol does not. This is important as transport of opioids into disaster zones can be frequently delayed because of customs restrictions. For all these reasons most experienced disaster response teams (such as MSF and the ICRC) rely heavily on ketamine anaesthesia.20,21 During the MSF response to the Haiti earthquake 90% of general anaesthetics were carried out under ketamine with only 10% of patients receiving a general inhalation anaesthesia.12 Again, most anaesthetists from high resource settings will not have had much experience with ketamine anaesthesia so pre-deployment training is required.
Regional Anaesthesia
Spinal anaesthesia is a common anaesthetic technique in this context and is usually considered for any patient requiring surgery below the umbilicus that is not shocked. There can be issues of communication so the presence in theatre of a translator or local staff member throughout the case is extremely important. It can be expected that around 20% of cases will be performed under spinal anaesthesia.12 Epidural analgesia and anaesthesia is not generally performed as a result of the difficulties of postoperative surveillance of patients.
Regional blocks are extremely valuable. Surgeries may be performed under regional block alone, although the nature of the injuries covering more than one site often means that it needs to be combined with general anaesthesia. It is still very useful in this context however as it reduces the amount of general anaesthesia required with speedier, safer recovery. In addition, it provides excellent postoperative analgesia.
Postoperative analgesia
Analgesia can be a real challenge in this setting with restricted supplies of opioids and inadequate postoperative patient monitoring as a result of overwhelming patient numbers. Regional block techniques, although gaining in popularity, are still relatively underused in this setting, but their safety and usefulness is established22,23 and they are recommended in the WHO/ICRC management of limb injury guidelines.24 Most emergency medical teams now deploy with portable ultrasound for a number of uses including regional anaesthesia, and so facility with ultrasound-guided lower limb, upper limb and some trunk blocks such as transverse abdominus plane and serratus anterior plane blocks is extremely useful.
Critical and perioperative care
Whilst Level 2 field hospitals are not expected to provide intensive care they will need to stabilise critically ill and injured patients – both medical and surgical. Ideally these patients would be transferred to a referral or Level 3 hospital but in practice this is not always possible. Usually a dedicated bed either in the emergency room or the recovery area (dependent on nursing skill mix and staffing levels) is set up for high dependency patients. The anaesthetist on the team may be the most senior person available to lead stabilisation of patients arriving in the emergency room and manage their care if necessary. Whilst this might not be a problem for surgical emergencies, management of medical emergencies may be less familiar. Crucially the team anaesthetist will also need to help with the medical management of ward patients with comorbidities such as diabetes mellitus and hypertension in addition to recognition and management of perioperative complications. The International Surgical Outcomes Study showed that in elective patients in lower resourced settings there were fewer complications compared with higher resourced settings, as might be expected when the patients had lower baseline risk. However the overall mortality rates were the same, suggesting failure to salvage from complications.25 It is likely that this risk would be even higher in the emergency setting and emphasises the fact that providing safe surgery and anaesthesia cannot be in isolation from good perioperative care.
Other roles
The anaesthetist on the team also needs to be prepared to take on a number of roles and tasks with which they may have no experience.
Pharmacy skills: keep an inventory of their drugs and disposables to make sure that they reorder supplies in good time, bearing in mind that resupply can take weeks; and monitor or delegate the monitoring of drug refrigerators including maximum and minimum temperatures for cold chain security for refrigerated drugs and vaccines.
Infection control skills: ensure that anaesthetic equipment is cleaned, disinfected and sterilised as appropriate.
Laboratory skills: perform simple tests such as Haemacue, malaria and infectious disease rapid checks and bedside blood group testing.
Management and teaching skills: manage a small team of local anaesthetic officers, and in the later stages of the emergency some teaching may be appropriate.
Audit and quality improvement: data collection is vitally important both to inform the health cluster and country Ministry of Health about the evolution of the emergency to improve coordination but also for analysis after the event to improve the response for future disasters. The anaesthetist on the team will have a role in physically collecting data and a leadership role in ensuring the completeness and quality of the data.
Personal considerations for volunteers
When can I volunteer?
Working in disaster response involves working unsupervised, and sometimes solo, in a very high-pressure environment both in terms of professional technical challenges and managing team dynamics. In addition, the anaesthetic role can involve working with and supervising experienced local anaesthetists. For these reasons, most EMTs require anaesthetists to be of consultant level or equivalent. Some teams who deploy with more than one anaesthetist have the ability to take anaesthetists in training, although priority for these places is usually given to anaesthetists of consultant grade who do not yet have overseas experience. Some EMTs (e.g. the UK EMT) allow trainees to sign up for training, be part of a community of practice and be involved in non-disaster response deployments. Any consultant volunteering needs to consider the requirement for often short notice deployments, with the need to be away for around three weeks, and whether this will be possible both professionally and personally.
Registration and insurance
In the EMT system registration with the local Ministry of Health is carried out on arrival at the Health Emergency Coordination Centre. Copies of relevant General Medical Council and Certificate of Completion of Training certificates must be provided. The practitioner is then provided with a disaster response identification card, generally with limited registration to work only in their own EMT facility. Medical indemnity insurance is usually provided by the deploying EMT, but this should be checked when signing up. Both the Medical Protection Society and The Medical Defence Union may also agree to extend protection to their members (at no extra cost) for carrying out this work, but this must be prearranged by phone on a case by case basis. Personal insurance for health, medical evacuation and kidnap is provided by the deploying organisation. But insurance against theft and loss of personal items is the individual’s own responsibility, and in many of the areas visited will not be possible to obtain.
Health and safety
Working in these environments carries inherent risks which whilst they cannot be avoided should be mitigated by responsible deploying organisations. Questions to consider are: is there someone on the team with responsibility for safety and security; what are the identified risks for this context; what has been done to mitigate these risks; what is the plan if one of these risks occurs; and does the benefit of the team being deployed outweigh these risks? If your deploying organisation is unable to answer these questions then you should think carefully before deploying. Potential risks depending on the context include: infectious diseases, transportation accidents, further flooding/aftershocks, etc, robbery, kidnap, and violence against the team as collateral damage and intentional targeting of the team.
One of the most common questions asked is regarding psychological health and the impact of working in these contexts. Most people who deploy will have no long-term psychological sequelae. The majority of people experience a stress reaction on returning to “normal” life after deployment often referred to as “re-entry syndrome” or “reverse culture shock,” and a minority may go on to experience burnout and in some cases post-traumatic stress disorder.26 To minimise these stress reactions and ensure any problems are rapidly identified and treated, deploying EMTs should have a psychological health programme for their volunteers. The content of these programmes is beyond the scope of this review, but should include specific briefing for the deployment (expectations), education on how to minimise stress and maximise resilience on deployment and management of re-entry, post-deployment debriefing (immediate and delayed), recognition of abnormal stress reactions and routes for getting help.
Progress so far and challenges for the future
The gold standard for disaster response is to have local emergency medical teams who are able to be operational within 12 h, providing a high standard of care and increased capacity, in order to manage life-threatening injuries from the disaster. These teams can then be augmented over 24–72 h by international emergency medical teams to provide increased capacity and more rapid management of non-life threatening injuries, thereby decreasing the burden of long-term morbidity and disability. These teams must also be prepared to help with both disaster and non-disaster related on-going demand for emergency surgical and medical care. The aim should be that both local and international teams would be working to the same set of minimum standards.
Local disaster response
The major challenge is how to provide that local emergency medical team response. Even countries with high levels of resources and well advanced disaster planning, such as Japan, struggle.27 There are four accepted pillars for local disaster preparedness:
Structural preparedness: ability of a structure to withstand the hazardous event.
Non-structural preparedness: ability of equipment to withstand the hazardous event.
Functional preparedness: ability of a hospital to operate properly such as availability of necessary drugs and disposables, sufficient beds, water and oxygen, etc.
Human resources: existence and ability of healthcare staff.
Most people who are affected by disasters live in low- and middle-income countries (LMICs). For many hospitals in LMICs providing these four pillars of preparedness just for everyday healthcare needs is a struggle let alone in the disaster setting.28–30 The priority currently for LMICs is to improve local healthcare infrastructure. This agenda has been strengthened in recent years by the Lancet Commission on Global Surgery31 and the World Health Assembly resolution to strengthen emergency and essential surgical and anaesthetic care.32 This is clearly a massive undertaking and further discussion of progress in this area is beyond the scope of this review. High-income countries still have work to do to attain this level of preparedness – especially around provision of local disaster emergency teams.27
International disaster response
These same four pillars of preparedness are also relevant for international emergency teams. In this area through the WHO EMT programme significant progress has been made. The WHO accredited teams will now arrive in the disaster zone with a suitable structure to work in, they will be using equipment that is suitable for the context and will have full logistical support providing their own water and electricity and sufficient medical supplies. The responding teams will have appropriate human resources for the capacity they are providing and these staff will have had training for the context in which they will be working.
There are still areas for improvement for the international response:
Speed of response
For many countries a high quality, high capacity local disaster response is not yet attainable. For this reason international emergency teams need to be able to respond as fast as possible. Whilst response time has been improving, for the most part, it is still too slow to help those with life-threatening injuries. Barriers to a rapid response and their potential solutions include:
Travel time: EMTs from the countries nearest the disaster should be invited to respond but this has not always been the case. The WHO EMT programme can play a key role in ensuring that the appropriate teams are activated.
Customs export and import restrictions: this can significantly delay supply of equipment, drugs and disposables to the disaster, with teams arriving days before their equipment. Customs problems can be reduced by having modules of drugs and equipment pre-approved by customs offices. Equipment and supplies can also be stockpiled in regions and countries likely to be affected by disasters.
Runway space and other transport restrictions: having modular systems enable teams to deploy with a smaller rapid response kit to provide life-saving treatment whilst awaiting the rest of their field hospital equipment.33 Pre-agreed standard operating procedures for air traffic control priorities in case of disaster can also improve the flow of staff and supplies.
Release of staff from existing roles: use of standby rotas and agreements with employers to release staff. The UK International Emergency Team has staff on three month rotas, with the pre-agreement of their employers that they will be released immediately for disaster response.
Whilst most teams and countries use some of these measures to improve response time few have all in place.
Training
Anaesthetists who formed part of an EMT in the past reported significant gaps in skills and knowledge for their role.34,35 This should not be surprising when one considers the technical differences and wider scope of practice discussed above. There are now a range of training materials and courses available for anaesthetists who wish to deploy with EMTs such as the Royal College of Anaesthetists’ online Humanitarian Anaesthesia eLearning module,36 the ICRC Anaesthesia Handbook for disaster and conflict,37 and the ICRC War surgery course. Pilot studies of on-line training have demonstrated self-reported improvements in preparedness once deployed.38
Whilst the WHO EMT programme mandates that anaesthetists should be trained, there is not currently an agreed curriculum for what that training should consist of.39 This is true for all the deployed specialties and an international group is currently working to produce agreed curricula.
Responding to conflict and outbreak disasters
The WHO EMT Initiative was primarily targeted at disaster response for natural disasters such as earthquakes and tsunamis. In recent years the WHO has also used the same framework to coordinate the response to the Ebola outbreak in West Africa. In the future there is no reason why it could not also be used to coordinate response in conflict as well. For anaesthetists responding to these disasters there are a number of different training needs compared with natural disasters: security, management of bullet, blast and chemical injuries, infection control and use of Nuclear, Biological, Chemical (NBC) suits or Personal Protective Equipment as required. Whilst the conflict role has many overlaps with response to natural disaster the role of the anaesthetist in outbreaks is very different. The anaesthetist may have a role in responding directly to the outbreak disaster (helping with fluid management, i.v. and intraosseous access, very limited critical care and some transfer of patients). But it is likely that in the future they will also be deployed as members of teams helping to provide normal emergency surgical and obstetric services to support healthcare systems that have broken down as a result of the effects of the outbreak.40
Audit, quality improvement and research
Coordinating and improving disaster response relies on good quality data. This can be a real challenge in the high pressure, extremely busy disaster context. Previously there has been no agreed data set for medical teams to collect in disasters. Some teams have not collected any data at all. Analysis of previous disasters has had to rely on collating incomplete and differing data sets from different organisations. The WHO EMT initiative has now produced a minimum data set to be derived from patient records and to be collected by all EMTs responding to a disaster.41 This should provide much better quality data for analysis of the effectiveness of disaster response and for disaster planning in the future.
Conclusions
The disaster context produces immense logistical challenges for responding EMTs and different types of disaster produce different patterns and timescales of injury and disease for teams to respond to. Understanding and being prepared for these different contexts is vital for an effective disaster response. The last seven years since the Haiti 2010 earthquake has seen enormous progress in the professionalization of disaster response. Through the WHO EMT initiative there have been significant improvements in the speed, coordination and quality of the international disaster response. The response is now much better matched to the needs of the affected population. There are clear standards for logistics, equipment, capacity and human resources for deploying teams and a process of accreditation. Anaesthetists have a key role to play, especially in the Level 2 emergency medical teams. The technical challenges and wider scope of practice in this context mandates that all deploying anaesthetists should receive training for anaesthesia in disaster response. Future challenges include improving local disaster response and organisation of local EMTs, reducing the time for teams to be operational in the field and agreeing training standards for deploying teams. Collection and analysis of the minimum data set will allow teams to compare and evaluate their response and help to plan more effectively for future disasters.
Declaration of interests
The author is a Volunteer Anaesthetist with Medecins sans Frontieres; Ex lead Anaesthetist UK Emergency Medical Team; and Member of International Committee of Red Cross – World Federation of Societies of Anaesthetists Liaison Committee.
References
EM-DAT International Disaster Database. Brussels, Belgium: Universite Catholique de Louvain. Available from www.emdat.be (accessed 18 August 2017)
Center for Research on the Epidemiology of Disasters (CRED). In: Scheuren JM, le Polain O, de Waroux R, et al. Annual Disaster Statistical Review 2008: The Numbers and Trends 2007 WHO.
Medecins sans Frontieres: Rapid Intervention Surgical Kit. Available from https://www.msf.ca/sites/canada/files/risk_kit.pdf (accessed 18 August 2017)
