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14 How to Establish a Trauma and Disaster Response Service in Low- and Middle-Income Countries…
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non-existent or, immature. It is therefore essential to advocate the need for an organized and
effective trauma system to the national and
regional governments, community, and other
stakeholders to bring it to the level of that found
in high-income countries (HICs). This is particularly important since the incidence of surgical
trauma in LMICs, and especially in Africa, is
higher than anywhere in the world and represents
the majority of surgical interventions [9].
Infrastructure of Trauma System
Since injury may be a complex phenomenon, it
needs the inclusion of distinctive methodologies.
As a result, considering the following pillars is
crucial [10].
Leadership
Leadership is a process that enables all members
of a group to achieve a common goal. Overall
trauma system leadership needs high-level
national and regional involvement and the support of the countries’ ministries of health, transportation, environment, security including police
and re departments, and insurance agencies.
The multisectorial steering committee should
support policy development, approve major decisions, and uphold system standards. A technical
team should concentrate on developing national
guidelines, gathering data, and monitoring the
current system with a particular focus on quality
and efciency. The integration of community rst
responders, an EMS team (if one is present), the
local health department, and hospital administrations entails system leadership in a particular city
or even hamlet. Case management requires leadership of emergency professionals and surgeons
selected from multitask teams necessary for specic types of trauma. A failed system is the result
of fragmented leadership and poor coordination.
Technology
Essential assistive technology, such as wheelchairs, crutches, splints, and orthotics, is often in
short supply in LMICs during the immediate
response to disasters. After stabilization of acute
trauma and termination of the disaster, long rehabilitation strategy requires early planning and is
also largely dependent on these assistive devices
which are frequently in low supply during disaster relief operations This lack of assistive technology affects not only those with new injuries,
but also those who may have displaced or damaged assistive technology because of the disaster
or conict. The overall consequence of such
inadequacies will be prolonged bed rest for the
victims who may suffer all the known complications of limited early mobilization (e.g., pulmonary emboli) or whose discharge home may be
delayed, which further impacts rehabilitation
capacity. Long-term rehabilitation strategy
involves early preparation and is heavily dependent on these supportive technologies after acute
response of the disaster. Also consideration of
non-functioning or damaged device replacement
should be in place. The overall effect of these
shortcomings will be prolonged bed rest for the
victims, who may experience all the known risks
of limited early mobilization (such as deep
venous thrombosis and pulmonary emboli), or
whose discharge home may be postponed, which
further reduces their ability to recover. Other
technology areas include video conferencing,
tele-consultation, and virtual reality assist to
advance trauma training and research. Few technological areas incorporate identication by the
use of Global Positioning System (GPS), initiation of a call to dispatch centers by emergency
access numbers, coordination of care by utilizing
telemedicine, trauma education technologies,
and arrangement of assistive devices.
Technological advances in trauma management
have already improved patient outcomes in the
pre-hospital care, in the emergency room, in the
operation theatre, in the intensive care unit, and
during inpatient care, primarily because of
improved monitoring, communication, ventilators, and even dressings (vacuum-assisted closure—VAC). Management of patients using
newer technologies like laparoscopy, invasive
monitoring, endovascular techniques, as well as
modern computerized mechanical ventilator has
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contributed signicantly to improvement of
trauma care and recovery, but their adoption in
LMICs is very slow and selective to tertiary centers because of the high cost of the equipment
and the need for trained technical support to
repair and maintain it.
Personnel
In addition to proper health care training, individuals who work in trauma centers must have
specialized trauma-focused training and experience. A multidisciplinary team of physicians,
nurses, paramedics, and administrators must be
involved in directing and training of trauma
teams. The number and type of professionals
included in each team depends on the size and
designated level of the facility. Level III centers
may require fewer trauma-trained professionals
to provide initial acute stabilization care and to
arrange transfers to better-equipped facilities.
Level II centers are intermediate units that provide general care and inpatient services and may
choose to care for patients who don’t need highly
specialized orthopedic, thoracic, vascular, neurosurgical, or other care. The most advanced center
is Level I with full complement of various ICUs’
intensivists and other highly specialized professionals in most areas of medicine and surgery, in
addition to having dedicated rehabilitation, physiotherapy, psychiatry, and social services.
Transfer protocols must be consistent and
transparent, written in collaboration with all
stakeholders from various hospitals, departments,
trauma leaders, and health care authorities who
must be ready to fund the effort. Such protocols
must be the main guidelines for triage and deciding which patients are transferred to which appropriate facility and when and how this should take
place. Trauma specialists with extensive experience of major trauma, and other clinical specialists for complicated conditions that may be part
of a traumatic injury are in short supply in
LMICs. This raises many problems which can be
partially resolved by appropriate triaging and
division of labor among the various stakeholders.
Continuity of care in most serious cases depends
heavily on the level of experience of rehabilitation professionals.
Education andTraining
Trauma education programs include short-term
training which facilitates acquisition of basic
medical knowledge and clinical skills, in addition to many specialized programs focused on
both very narrow medical and surgical areas
and/or on broad areas of organization, supervision, recruitment, fundraising, and on education itself via practical supervised practice
exercises. Trauma evaluation and management
course is an introductory course for medical
students in many African countries, which can
be easily extended and expanded to instruct
professionals working in low-level centers
(Levels II, and II). More advanced training
courses, including Advanced Trauma Life
Support (ATLS), are not widely available
although they are required and essential in
low-resource settings. The cumulative effect of
inadequate medical education among nonmedical professional staff puts Trauma programs in LMICs at a major disadvantage which
can only be corrected by an increase in organized advocacy aimed at the public, the doctors, and at the policymakers, especially those
in health ministries of LMICs.
Information Management
Numbers speak more than words. While there are
major digital advances in information management in HICs, health information management
system is generally poor in LMICs. The accurate
statistics on trauma in the system are not available but are estimated to be high. It has become
clear recently that more accurate data may
inuence national and professional changes
favorably and most importantly, inuence signicantly the budgetary allocations to improvement
of national trauma care which is badly needed in
most LMICs. Due to disproportionate growth of
population in existing living conditions most of
the societies in LMICs are vulnerable to injury.
All advocacies, public education, and planning
are being made based on available information.
The WHO trauma registry system is being utilized only in a few settings. Trauma database
should be one of the priority areas in all health
facilities.
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Finances
Injuries often occur in emergency conditions in
areas where victims may not be nancially ready
for health care. Few governments give free service while others request large compensation. To
alleviate this discrepancy all stakeholders should
work to optimize health insurance coverage.
Trauma care is very costly and requires signicant resources. The cost of imaging, operation,
and rehabilitation care is high compared to standard medical care. Training and research are the
other nancial need areas.
Disaster Preparedness and Response.
Disaster preparedness plan is a process which
includes development of emergency plans and
early warning systems to respond rapidly and
cope effectively during disaster situation.
The disaster-planning phase is a continuum of
activities starting from (1) baseline assessment,
(2) event management, and (3) rehabilitation process. All stakeholders must agree on their role in
the communal effort so that they can all rely and
have condence on this jointly created infrastructure. The implementation of the specic plan is
the response phase. Disaster response may
involve EMTs, re brigades, police departments,
and industries. All should respond in a coordinated manner.
The response phase focuses primarily on
emergency relief, i.e., saving lives, providing rst
aid, minimizing and restoring damaged systems,
such as communications and transportation, and
providing care and basic life requirements to victims (food, water, and shelter). Response activities need to be continually evaluated and adjusted
to the changing situation.
The preparedness, planning, and periodic
drills enhance the ability of a hospital’s team to
respond to most of the challenges encountered in
trauma and to continue to function in disasters.
Constant growth and improvement must remain
the goal of the team, even during times when it is
not needed so as to remain well prepared when
eventually faced with a medical and social
disaster.
Transportation
Proper transfer protocol is necessary to ensure
availability and proper selection of types of transport. Basic and advanced ambulances can be
deployed based on the need. Air ambulances can
be arranged by using military helicopters in
resource-limited settings. In places where the
disaster happens near a water source boats can be
refurbished to serve as ambulances. Availability
of the various modes of transfer must be planned,
foreseen, and practiced. The plans will differ
according to the site and the extent of the
disaster.
Triage
Jump START triage (Simple Triage and Rapid
Treatment) is a simple triage system that can be
performed by lightly trained lay and emergency
personnel. It was developed at Hoag Hospital in
Newport Beach, California for use by emergency
services. It is based on the principle of walking
and non-walking victims.
Triage separates the injured into four groups:
• The injured who are beyond help.
• The injured who can be helped by immediate
transportation.
• The injured whose transport can be delayed.
• Those with minor injuries who need help less
urgently.
It also sets priorities for evacuation and trans-
port as follows:
(a) Deceased are left where they fell. These
include those who aren’t breathing and
where efforts to reposition their airway were
unsuccessful.
(b) Immediate or Priority 1 (red) evacuation by
an ambulance (or by other means like a helicopter) is reserved for those who are in critical condition and need immediate (or within
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1 h) advanced medical care in order to
survive.
(c) Delayed or Priority 2 (yellow) victims can
have their medical evacuation delayed until
all Priority 1 patients have been evacuated.
These individuals are in stable condition but
require careful medical or surgical
management.
(d) Minor or Priority 3 (green) victims are evac-
uated after all Priority 1 and 2 victims have
been evacuated. These will not need advanced
medical care for at least several hours.
Continue to re-triage in case their condition
worsens in which case they will jump to a
higher Priority. These Individuals are able to
walk and may only need bandages and
antiseptic.
Essential Components ofDisaster
Preparedness
The following components serve to summarize
the technical processes and operational mechanisms required to ensure the effective, and safe
function of a preparedness plan:
Disaster Management Committee
Establishing a disaster/emergency/committee is
the rst step for making a disaster plan for the
nation as well as health care facilities. If one
already exists, it needs to conform to the universal established requirements for the country or
the region as appropriate.
Compositions:
• The Chief Executive Director of the
institution.
• Member/members from hospital management
board.
• The chiefs/heads of various clinical departments supporting the emergency services.
• The chiefs/heads of various ancillary
departments.
– Including radio-diagnosis, laboratory/
pathology, blood bank, and forensic
medicine.
– Infection control.
– Pharmacy and pharmaceutical supplies.
• The chief nursing service director/matron.
• Heads of Administrative Departments including; nance, procurement, and asset
management.
Note that:
• There should be a backup member for each
category, in case the assigned member(s) in
charge of a section is unavailable to perform
tasks during the event of an emergency/
disaster.
• The copy of the preparedness plan should be
communicated and available for each department of the hospital.
Incident Command System
Incident command system (ICS) is necessary to
ensure effective control and avoid duplication of
action. There needs to be a unied command system which should be based on the individual hospital hierarchical chain of command.
All emergency operations must be managed
by an ICS.It is a method for dealing with disasters when the situation requires coordination of
all hospital activities through a single loop of
command post communication system.
ICS is managed by six main command post
leaders:
Commander—Chief Executive Director.
Operation leader—Chief of Disaster Management
Team.
Logistics—Chief of Pharmacy and Purchasing
unit.
Finance/administration—Chief of Finance.
Information—dissemination of news and
progress.
Public health—Chief of Public health.
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Each other hospital unit, area, or department
continues to maintain the same leaders or directors as they have per their regular routines,
regardless of their additional function on the ICS.
Chain ofCommand
Whenever the hospital units, areas, or departments need to communicate with ICS, they
should do so via the Command Post leader
assigned to that particular function.
How toActivate Disaster Response
Disaster Alert should be provided to the hospital
staff and/or patients when activation of
Emergency Operations is probable or anticipated in the near future. The information should
include the type of causalities, place of disaster
(distance from the center), and estimated number of victims. The plan is activated after the
rst patients arrive at the hospital and/or when
the team moves to the scene of disaster or of
emergency.
Only the Incident Commander has the authority to activate the hospital disaster response. He/
she must announce the following notice to the
hospital staff with a loudspeaker and available
social media platforms: “Attention! Attention!
Attention! All staff and visitors, Disaster
Activation is now in effect for the emergency that
has happened in the city, please implement the
Hospital Disaster Plan”. This should be
announced in the ofcial language of the country
and the local language of the area.
Initial Assignment ofResponsibilities
As soon as there is a disaster alert declared, the
communication loop between the disaster team
and stakeholders should be put into operation. All
off-duty staff should be prepared for possible
recall to the hospital by the hospital director.
Disaster store should be replenished with
emergency drugs and resuscitation equipment.
The key or the combination to the store should be
placed with the director of ER and be available
for 24 h each day of the ongoing disaster
activities.
Surge Capacity
Newly arriving patients require admission for
denitive treatment. It is therefore necessary to
put into effect plans to increase the bed capacity
of the hospital. This can be achieved by opening
areas with nursing supervision that are not
employed for other reasons, to accommodate
hospital beds and necessary equipment for the
new patients. This can be achieved by the following actions:
• Discharge elective cases.
• Discharge stable recovering patients.
• Stop admitting non-emergency patients.
• Convert waiting/non-patient care areas into
makeshift wards.
• Transfer patients to lower level health
facilities.
Planning forDisaster Beds
Critical areas including ERs, ICUs, and ORs
should be cleared of many of their current routine
functions and of their impending functions (e.g.,
postpone elective surgeries; discharge nonemergent, etc.). Open space on surgical wards
and even in the corridors may serve as temporary
areas for admission of patients who are in the ER
irrespective of their clinical diagnosis.
Mechanical ventilators, suction machines, monitors, and other ICU equipment should be used
according to their availability anywhere they are
needed at the time of disaster. There might be
sharing of resources in all service areas of the
hospital as per the Operation Leader.
Patients can be admitted to ER utilizing all
possible spaces including stretchers, boards, or
beds. Patients should be marked with their paper
triaging category based on the severity of injury
when initially found. This facilitates identica-
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E. T. Shimber
tion of the patients and the severity of their injuries. This also guides the selection of the
management approach for each individual
patient. All Public hospitals should be part of the
disaster response team.
As mentioned previously the injuries are triaged and therefore marked by the following
Categories: RED, YELLOW, GREEN, AND
BLACK.
Other Services
All ancillary services must be notied of the
alert. Representatives of the services must make
themselves available to provide their expert services when called on by the responsible physicians caring for the victims.
Imaging service will be provided by members
of the radiology department staff including
CT-scan, X-ray, and Ultrasound services when
requested by the physicians providing care.
Laboratory service: Both emergency and central laboratory service should resume full capacity especially if the disaster is at night. Personnel
should be recalled from home to increase the
skeleton night roster. Extra blood for transfusion
should be prepared and provided by the blood
bank as soon as possible. Obtaining any available
blood from other hospitals may be necessary and
recruitment of new donors should be initiated to
replenish the available blood stores both for victims of the disaster and for daily needs of regular
patients.
Pharmacy service: All disaster trauma patients
may partially rely on the disaster mini-stock.
This should provide all the necessary equipment
and medications. More drugs should be obtained
from the ER or other pharmacies without any
restriction.
Security service: Apart from guards on each
shift, there should be reassignment of two guards
to the ER gate to prevent unauthorized entry to
any visitors, reporters, and anyone who is not
either a patient or member of the team or of the
staff. City police assistance might be needed in
case of an uncontrolled crowd or disorderly and
insistent visitors.
Chart and recording room: If electronic medical records are not available, paper-based charts
should be employed in the ER for all victims to
maintain accurate records at frequent intervals.
Charting new medications, vital signs, intake &
output, unusual events during treatment or evolution of the original injury must be recorded in a
timely manner right after its occurrence. A designated person must record basic components of
the history and of the procedures.
ER staff arrangement: Patients should be
admitted to ER without any delay. Triaging can
be done simultaneously with the patient admission evaluation. All available ER staff on the shift
should be reassigned to the RED ZONE while the
disaster team takes care of all the other trauma
categories.
The disaster team, most of whom visit the ER
frequently, includes General surgeons,
Neurosurgeons, Orthopedic surgeons, ER physicians, Surgery residents, midwives, lab techs, ER
nurses, ICU nurses, Pediatric ER nurses, OR
nurses, Ortho nurses, pharmacists, anesthetists,
anesthesiologists, and support staff dedicate most
of their efforts in the areas where they are usually
assigned. Further arrangement of human resource
will be done based on necessity and is directed by
the Operation Leader.
Initial management meeting after rst phase
response: Following the initial rush of patients to
the ER following a disaster and disposition of the
rst wave of victims, a brief pause must be taken
to conduct an initial management meeting following the rst phase response. During that time
discussion must be directed to improve the ow
of patients, if possible, and make minor adjustments in distribution of staff, formation of new
patient areas, and establishment of priorities,
especially in ICUs and ORs. This is briey summarized below.
1. Discuss the overall situation with Command
Post Staff.
2. Establish action priorities based on the rst
response.
3. Detail resources that are now available or in
shortage.
4. Report the current state to stakeholders.
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Visitor’s Policy
Accompanying persons are not permitted. All
visitors should be directed to the waiting area so
as not to interfere with the busy trafc of patients
and their providers in the ER.Others should leave
the compound as soon as possible. This could be
challenging in highly dense areas so that different
strategies can be considered to control the crows.
Trauma Resuscitation Training
Trauma resuscitation is a multidisciplinary and
multiprofessional process practiced daily in
trauma management. The team should have a
pre-dened role with one leader. Skill and knowledge have been shown to increase with regular
simulation and practice drills.
The training encompasses and intends to evaluate rst aid practice in staged emergency-scene
events. This practice includes evaluation of competence in communication among EMS team and
their ability to appropriately transfer victims to
the nearby health facility.. Part of such training
includes initial evaluation of expertise in hospital
triage, need for subsequent intervention, and
eventual decision regarding placement. The training also includes learning about external communication and liaison system which must be
practiced effectively in any disasters that cause
signicant damage. After completing the training, each participant must receive performancebased feedback and instructed on how to improve
their efforts.
There is also a need for training of nonmedical personnel such as policemen, remen,
and especially EMT personnel, in how to treat the
patient and how to transfer the patient to an
appropriate health facility. Before arrival at the
hospital, pre-hospital providers (generally nonphysicians) should transmit information about
the mechanism of injury, the status of the patient,
and initial treatments given in the eld. This
information can result in furthering the management plan. All the necessary equipment and
resources may be prepared on the basis of this
initial report. After the patient arrives at the health
facility a written handover should be done to
inform the local staff of all the necessary details
needed for continuity of care. Essential elements
that should be obtained in this report include
details about the injury event, vital signs obtained
at the scene and during transport, pertinent physical ndings, and the initial treatments administered along with the response to these treatments.
In the receiving hospital activated trauma team
should then assume responsibility for the patient
based on standard protocol.
Disaster Drill
A drill is a practical exercise which teaches the
application of skills and techniques that would
be needed in real situations to manage hypothetical emergency situations which simulate real
damage and injuries that may be encountered in
a disaster or an emergency. Such drills require
the actual mobilization of personnel and the use
of material resources, communication, collaboration, triage, disposition, and treatment in the
eld. During the drill an experienced and knowledgeable supervisor evaluates on a scoring sheet
the procedures, tools, skills, individual and institutional capacity, and everything else pertinent
to management of an emergency/disaster in relation to the institutional plans for disaster preparedness and response. The overall aim of the
drill is to identify specic weaknesses that can
be targeted for improvement and to promote
continuing efforts to strengthen hospital disaster
preparedness.
How ToCoordinate aResponse
intheSetting ofPublic Health
Emergency
COVID-19 Lessons fromDierent
Environments
A pandemic at large and epidemics in a regional
context have had a signicant negative impact on
social, psychological, and economic sectors so
far. The COVID-19 pandemic overwhelms the
health care system not only in LMICs but also in
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E. T. Shimber
resource intense countries. Collaboration and
integration among different stakeholders may
reduce the effect of public health emergencies.
Health care systems in LMICs are known to be
weak. In the face of a highly transmissible pandemic, they become more fragile since they have
a little reserve. Accessibility and efciency of
health care systems prevent, detect, and treat disease effectively through primary health care.
Shifting of resources for COVID-19 care is
expected to compromise the effectiveness and
use of other services. Health systems worldwide
were challenged by the increasing number of
patients with COVID-19. This overwhelmed
health care systems everywhere to a greater or
lesser degree and therefore compromised the
delivery of other health care to non-COVID
patients due to various factors. These included
marked and rapid decrease in available supplies
and even equipment, like ventilators, and partially because of decrease in personnel due to illness or fear of exposure to the virus, stigma,
misinformation, and limitations on contacts.
When health systems are disrupted and people
fail to access needed care, both direct mortality
from an outbreak and indirect mortality from preventable and treatable conditions increase dramatically. The optimization of infection
prevention and control via vaccinations and mask
and distance precautions is the core part of maintaining non-COVID-19 health care system.
The challenges to weak health care systems
are magnied in these situations because of the
need for shifting of professionals (already inadequate in number) for COVID-19 care and isolation of staff and needed personnel who may be
infected. This causes additional disruption of
delivery of non-COVID care. The supply of drugs
and equipment is also disrupted due to factories
shifting to COVID-19-related protective equipment production, which may lead to a mismatch
of demand and supply.
Pandemic response strategy should consider
engagement of non-health sector organizations,
international partners, local community members, and media to promulgate energetically all
possible preventive measures, including mask-
ing, isolation, frequent washing, and especially
vaccination when available.
Conclusion
This chapter on the management of disasters and
emergencies focuses on organization of a standard approach to consistent and responsible leadership, frequent re-evaluations and re-adjustments
of personnel, resources, hospital capacity, and
transport systems to accommodate a changing
number of victims with variable injuries.
Emphasis is placed on a careful triage system
which also may need to be adjusted periodically.
The focus of this chapter is how to combine xed
and relatively rigid approaches to the management of victims of disasters and at the same time
maintain exibility to accommodate moment-tomoment changes within the relatively xed infrastructure needed to maintain discipline and
cooperation among the providers and nonprofessional staff.
References
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in low-and middle-income countries: a review. J Surg
Res. 2015;193(1):300–7.
6. Eisner ZJ, Delaney PG, Thullah AH, Yu AJ, Timbo
SB, Koroma S, et al. Evaluation of a lay rst
responder program in Sierra Leone as a scalable
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How ToSelect aDatabase Software
https://t.me/medicina_free
forSurgical Data inLowandMiddle-Income Countries
HenryM.Spotnitz andMatthewE.Spotnitz
A man only becomes wise when he begins to calculate the approximate depth of his
ignorance.
– Gian Carlo Menotti
15
Abbreviations
DOD Day of Discharge
DOS Date of Surgery
Dx Diagnosis
RDBS Relational database structures
SQL Structured query language
Introduction
Some databases are optimized for multiple users
and provide exibility in data content, whereas
others are better suited for homogeneous data
content and fewer users. Database options include
at le and relational structures (RDBS). Flat
les contain information and a program that
accesses it. A common example of RDBS is a
Microsoft Excel spreadsheet. The structure is
simple and programming is not demanding. Data
entry and retrieval is straightforward. However,
applications are limited. RDBS consists of information that is distributed over multiple tables.
H. M. Spotnitz (*) · M. E. Spotnitz
Columbia University Vagelos College of Physicians
and Surgeons, New York, NY, USA
e-mail: hms2@cumc.columbia.edu;
mes2165@cumc.columbia.edu
The data are entered and retrieved by the structured query language (SQL) [1, 2].
How ToChoose aProgram
There are advantages and disadvantages to each
kind of database. For small populations, at le
databases have benets of being inexpensive and
easy to implement. Because of the widespread
use of at les, many surgeons are likely to be
procient with them. Alternatively, there is an
abundance of resources to help people who are
not familiar with their use. Flat les may be efcient for tracking a small number of variables
that are relevant to a surgical service, such as
basic patient information, the type of operation,
and the length of stay in an ambulatory care service. However, for larger and more complicated
data sets, RDBS offers unique advantages. The
distribution of data over multiple tables allows
for different data formats to be stored, as well as
the relationships among them. For large data sets,
SQL queries are more efcient than searching a
at le and those queries are also efcient at ltering duplicate entries. Furthermore, the
RDBMS structure allows for access to multiple
users. Disadvantages of RDBMSs are that they
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
M. A. Hardy, B. R. Hochman (eds.), Global Surgery,
149
https://doi.org/10.1007/978-3-031-28127-3_15
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