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Table 12.1 Common PACU issues and emergencies
Issue First priority Other additional steps
Bleeding
(post-surgical)
Bleeding
(post-partum)
Hypotension – Place patient in trendelenberg
Hypertension – Evaluate and treat pain
Altered mental
status
Chest pain/
myocardial
ischemia
Hypoxia/
respiratory
depression/arrest
PONV – Administer antiemetics
Pain – Administer multimodal analgesics
Sepsis – Administer uids.
– Contact surgeons
– Apply pressure (if possible)
– Administer uids
– Blood transfusion if necessary
– Contact obstetrician
– Fundal massage
– Insert Bakri balloon
– Administer uids
– Activate transfusion on standby
– Administer uid bolus
– Initiate vasopressors if needed
– Administer antihypertensives if
needed
– Evaluate cause
– Maintain patient in safe recovery
environment (for both patient and
staff)
– Reorient patient
– Administer sedatives as needed for
safety
– Administer oxygen
– Obtain EKG
– Consider administering ASA
325mg chewed
– Administer oxygen
– Sit patient upright
– Consider administration of
naloxone if appropriate
– Administer IV hydration
– Maintain patient in the upright
position
as appropriate, including
paracetamol, NSAIDS, opioids
– Start broad-spectrum antibiotics
– Initiate vasopressors if needed
– Acquire baseline labs
– Establish further IV access
– Contact operating room to initiate possible
re-exploration if appropriate per surgical
recommendations
– Acquire baseline labs
– Establish further IV access
– Contact operating room to initiate possible
re-exploration if appropriate per surgical
recommendations
– Determine the source of shock (cardiogenic,
hypovolemic, distributive, obstructive)
– Bedside POCUS
– Examine wounds or surgical site for bleeding
– Restart home medications if needed
– Consider cross-sectional imaging if AMS is sudden
onset, accompanied by other neurological decits,
and/or fails to resolve in an appropriate time
trajectory
– Establish steps for potentially activating transfer of
further care
– Consider CXR/POCUS
– Consider plan for airway support
– Consider placement of NGT if refractory emesis
and aspiration risk
– Discuss with surgeons and anesthesiologists
possible iatrogenic pain causes if the pain is out of
proportion to expected trajectory/physical exam
– Acquire labs such as CBC and lactate
– Consider imaging if the source of sepsis is unclear
T. Brentjens and R. H. Martinez
each institution develops its own evidence-based
rules and protocols for responding to common
emergency scenarios, as well as reviews them
regularly with on-site staff to remain prepared to
act promptly, effectively, and safely to improve
patient care when these instances arise. It is
beyond the scope of this chapter to provide complete algorithms for all potential complications.
Outlined in Table12.1 is a list of some steps that
can be initiated during the immediate response to
common issues and emergency situations that
arise in the PACU.
Quality Improvement
The PACU serves an additional important role of
being a testing ground for innovation in the hospital. As a high-throughput center of patients whose
efciency and safety standards affect both out and
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129
inpatient services, the reach of the PACU’s inuence as a leader among the hospital wards cannot
be underestimated. Quality improvement projects
can be trialed, studied, and implemented with
wide rippling effects. Throughput optimization, in
particular, can help improve safety for patients in
the PACU as well as the rest of the admitted
patients in the hospital.
Conclusion
Overall, the PACU is a cornerstone of supporting
functional and safe operating theatres and hospitals. When establishing or optimizing a PACU, particular attention should be given to space, personnel,
supplies, and preparation of emergency responses
while caring for this diverse patient population.
References
1. Cutugno C. Evolution of postanesthesia care units:
a legacy of politics, funding, and patient safety concerns. Policy Polit Nurs Pract. 2013;14(3–4):142–50.
2. Simpson JC, Moonesinghe SR. Introduction to the
postanaesthetic care unit. Perioper Med (Lond).
2013;2(1):5.
3. Prien T, Van Aken H. The perioperative phase as
a part of anesthesia. Tasks of the recovery room.
Anaesthesist. 1997;46(Suppl 2):S109–13.
4. Schad S, Booke H, Thal SC, Bentley AH, Booke
M.The recovery room: transition from a sleepy postoperative unit to a vibrant and cost-effective multipurpose perioperative care unit. Clinicoecon Outcomes
Res. 2021;13:893–6.
5. Mittel AM, Panzer O, Wang DS, Miller SE, Schaff
JE, Hastie MJ, etal. Logistical considerations and
clinical outcomes associated with converting operating rooms into an intensive care unit during the
coronavirus disease 2019 pandemic in a NewYork
City Hospital. Anesth Analg. 2021;132(5):
1182–90.
6. Pedersen T, Nicholson A, Hovhannisyan K, Moller
AM, Smith AF, Lewis SR. Pulse oximetry for perioperative monitoring. Cochrane Database Syst Rev.
2014;2014(3):CD002013.
7. Ramsingh D, Singh S, Canales C, Guran E, Taylor
Z, Antongiorgi Z, et al. The evaluation point-ofcare ultrasound in the post-anesthesia unit-a multicenter prospective observational study. J Clin Med.
2021;10(11).
8. Dahlberg K, Brady JM, Jaensson M, Nilsson U,
Odom-Forren J. Education, competence, and role of
the nurse working in the PACU: an international survey. J Perianesth Nurs. 2021;36(3):224–31 e6.
How toEstablish andMaintain
https://t.me/medicina_free
aFunctional Operating Room
inaLow-Resource Environment
RobertNeighbour, RichardRaker,
andRichardSmiley
To know just what has do be done, then to do it, comprises… philosophy of practical life.
– William Osler
Abbreviations
HICs High-income countries
LMICs Low- and middle-income countries
ORs Operating rooms
PACU Postoperative care unit
Introduction
The World Federation of Societies of
Anesthesiologists recommends minimum standards for the safe practice of anesthesia [1]. Most
low-resource settings are unable to achieve these.
A survey of 590 facilities in low- and middleincome countries (LMICs) showed that 40% of
hospitals had no anesthesia machines, 35% had
no access to oxygen, and many had limited availability of essential medications, lack of support
R. Neighbour (*)
Institution of Engineering and Technology,
Diamedica (UK) Ltd, Barnstaple, UK
e-mail: r.neighbour@diamedica.co.uk
R. Raker · R. Smiley
Columbia University Vagelos College of Physicians
and Surgeons, New York, NY, USA
e-mail: rkr1@cumc.columbia.edu;
rms7@cumc.columbia.edu
13
services such as laboratory and blood bank, and
lack of technologies such as advanced airway
devices and invasive monitors [2]. These standards were designed for permanent installations
where local practitioners practice in LMICs. The
general lack of national or regional infrastructure
such as power, clean water and lighting in many
low-resource areas of the world is well documented but this is particularly problematic in
health care facilities This is often compounded
by environmental factors such as temperature,
humidity, dust, and insect infestation. Working
within these constraints requires an understanding of the issues and their causes, much additional planning, and most importantly, always,
exibility.
When practitioners from high-income coun-
tries (HICs) plan to work in LMICs, they usually
try to bring equipment, supplies, and make physical improvements in an attempt to at least
approach the prescribed standards. To accomplish this a good sense of the existing status and
framework is essential. Available equipment,
often donated from HICs, despite good intentions, is frequently outdated, broken, or inappropriate for local needs. Even materials brought for
specic missions often end up less than useful
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
M. A. Hardy, B. R. Hochman (eds.), Global Surgery, https://doi.org/10.1007/978-3-031-28127-3_13
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due to electrical incompatibility and lack of spare
parts or repair/maintenance expertise.
Overall Physical Structure
andLayout
One of the rst important tasks of the surgical/
anesthesia visiting teams is to assess the physical
structure of the actual operating room; size of the
room, condition and exibility of the operating
table, lighting, storage, etc. Obviously, some
inventory of the surgical instruments available
should be made. The anesthesiologist will want
to inspect the anesthesia machine and ventilator,
oxygen and other gas sources as well as suction.
In the case of a team that is traveling to a site for
a brief temporary surgical mission, or a longer
visit that requires the creation of a more permanent installation and project, some of this assessment and inventory can be done before arriving at
a site, by phone or email communication and of
course now, the easy availability of photographs
and video.
An assessment should also be made of how
patients arrive at the hospital and are transferred
within the hospital to the operating room area.
Many patients may not arrive at hospital by conventional means, internal transfer may be very
slow and during this they may be exposed to the
elements. They may be, unaccompanied by medical staff, and their medical information may be
limited; the transferring patients may not have
the use of oxygen or other equipment, monitoring, or drugs. Many of these limitations may not
be modiable, or may be only capable of being
changed minimally, if at all. Any deciencies
must at least be understood and considered.
The postoperative areas should also be
inspected or inquired about. Is there a dedicated
postoperative care unit (PACU) or can one be created near the ORs? What will be the monitoring
availability and standard of personnel, and are
oxygen and airway management devices available, is there ventilation capability? Similarly,
where will the patient be housed after recovery
before being discharged? Is there a unit and team
to support intensive care (e.g., mechanical venti-
lation, prolonged homodynamic monitoring,
intravenous infusion pumps)? The resources
available in the postoperative area will impact on
the nature of surgery that is possible, and on the
anesthesia management options.
Personnel
The needs and concerns regarding personnel will
vary greatly depending on the specic nature of
the surgical/anesthesia enterprise, but unless all
personnel and expertise is being brought in to the
low-resource environment some attention must
be paid to what expertise or training the staff at
the site possess. It is well known that there is a
critical shortage of surgeons, anesthesiologists,
and obstetricians in LMICs [3] and in fact, anesthesia care is often provided by non-physician or
non-nurse personnel [4]. In general, “task sharing” occurs, where non-specialized physicians,
nurses, or less qualied health care workers ll
the provider gap. Will there be someone who can
get equipment or supplies and medications for
the anesthesia team in an emergency, help with
patient positioning, or even perform more “medical” tasks such as preparing syringes with drugs,
or providing cricoids pressure during an intubation? On the surgical side, are there staff who can
perform the roles of scrub technician and circulator, or surgical assistant? The need for interpreters, perhaps capable of handling multiple
languages, should not be underestimated.
Electricity
The presence and reliability of utilities needs to
be determined, by report or by inspection. The
reliability of electricity is problematic in many
low-resource environments, and should be
assessed by communication with local practitioners. There are two common “grid” electrical
supply formats in the world, 220-volt 50Hz and
110-volt 60 Hz. Ensuring that any equipment
purchased or donated to a facility is the correct
voltage and frequency is a necessary foundation
for equipment survival. Voltage can be altered for
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133
either format by the use of a transformer, but this
will not change the frequency, and incorrect frequency will often result in early equipment failure. Fluctuations and failure of grid supply are
common and can cause damage to equipment and
risk to the patient if the operator is unprepared.
What is plan B when the electrical power goes
out? What equipment will fail without external
power, and which devices are critical? Voltage
stabilization, protection devices, and battery
back-up systems are available and should be considered at the supply stage along with emergency
lighting, but if these are not available, a plan for
that (expected) emergency is required. Many
facilities have an alternative power supply such
as a generator but these are unlikely to start automatically following a grid failure. Generators
require manual starting, assuming they have fuel,
are ready, and an operator is available. It is always
worth reviewing the process and availability prior
to it becoming necessary. If they are available
battery back-up systems, that will prevent interruption of electrical power for OR devices should
be maintained in a fully charged state. An increasingly common device is the UPS (Uninterruptible
Power Supply). These should be switched on
before use to ensure the battery back-up is available, and batteries charged and switched off after
use to ensure the batteries are available when
needed.
Electrical safety in many low-resource locations can also be less than optimal. Circuit breakers and fuses may not be present or functioning
properly. Attention should be paid to the potential
of shock hazard caused by unshielded wires,
overloaded sockets, and trailing leads, particularly in theaters where there is liberal application
of water for cleaning.
Environmental Conditions
andConsiderations
Extremes of weather, temperature, and humidity
can have a range of unexpected consequences
beyond the obvious uncomfortable effects on the
medical personnel and patient. Ambient temperatures approaching 50°C (120°F) are uncomfort-
able, but are also approaching the boiling point of
volatile anesthetic agents and, where available
monitoring does not include this parameter, caution should be shown. Even inlocations such as
Sub-Saharan Africa patients get cold, and in
many situations the air-conditioning systems
used by staff exacerbate this. Patient warming
equipment and uid warming equipment are not
often available and unconventional patient warming may be common. For example, lling of
gloves with warm water and wrapping in cotton
or aluminum foil are common methods of warming babies and small children.
Oxygen Supply
Oxygen in low resource areas of the world can be
expensive and is often unavailable; it may be a
major element of a hospital’s budget. Despite
being classied by WHO as an essential medicine, it is often a scarce resource in these locations and should be considered as such. If oxygen
is supplied in cylinders (as opposed to an oxygen
concentrator) the anesthesiologist has obligations
to ensure its availability before commencing with
a procedure and to protect continuity of supply
and avoid unnecessary or excessive use. Many
cylinders are not in optimal condition. Regulators
and tubing may be subject to leakage. The small
back-up cylinders that are mandatory in HICs
may be empty or unavailable.
In many areas the common alternative to pressurized oxygen supplied in cylinders or piped gas
systems is the use of oxygen concentrators, which
entrain ambient air and remove most of the nitrogen with the use of molecular sieves. These
devices can provide dry oxygen at up to 95%
purity at either 5 or 10 liters per minute. They are
a very good source of oxygen, generated at the
point of use, and avoid logistical problems associated with the movement of oxygen cylinders.
However, oxygen concentrators do require a constant supply of stable electrical power, some regular maintenance, and have limited outlet
pressures. The limited outlet pressures make the
oxygen supply unsuitable to use with many
conventional anesthetic machines, although there
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are anesthesia devices and ventilators specically
designed to run at these lower oxygen supply
pressures such as draw-over circuits.
Concentrators can be particularly useful in
PACUs and ICU areas postoperatively where
positive pressure ventilation may be less often
needed [5].
In extreme situations the anesthetic technique
may have to be altered based on the available
oxygen, even to the point of accepting a lower
FiO2 than would normally be utilized in HICs, in
appropriate patients. The routine use of supplemental oxygen during regional anesthesia or mild
sedation, as is common in HICs, might have to be
re-assessed, based on patients’ needs and clinical
condition. It should also be noted that postoperative areas may not have the availability of oxygen
expected in better-resourced areas.
Anesthesia Machine
There are a number of common equipment constraints. The simple lack of available equipment,
such as the situation where suction may be shared
between the surgeon and the anesthetist, or the
unavailability of the ideal airway equipment
including endotracheal tubes, or supraglottic airways, can usually be overcome with some negotiation and exibility in technique. However even
if anesthetic techniques are going to be very
restricted, some means of delivering a volatile
anesthetic agent, maintaining an airway, and ventilating the patient are going to require a functioning anesthetic workstation.
The usual inputs to the modern anesthetic
workstation in a well-resourced location would
be three gases; oxygen, air, and nitrous oxide, as
well as a constant, assured, and stable electrical
supply. In the low-resource setting, it is more
likely to be simply an oxygen source and a reasonable electrical supply, with, hopefully. a
backup electrical supply. Since in most cases a
surgical team will not bring completely functional anesthesia machines on a mission, understanding the available machine(s) and their
constraints before use is vital. It may be an unfamiliar type, with complex gas circuit arrange-
ments, and have non-functioning elements and
limited monitoring. It is essential to carry out the
normal recommended pre-use checks (hopefully,
but not always, guided by an instruction manual)
followed by an assessment and trial of the effect
of loss of inputs such as electrical power failure
or gas supply, and a plan for what the response to
that situation would be. An alternative to the standard anesthetic system is the use of low- resistance
systems suitable for draw-over circuits [6].
Although the agent use may be higher, the reduction in oxygen usage by using it to supplement
room air entrainment offsets this cost implication
particularly with a spontaneously breathing
patient. It should be noted that the requirement
for patient monitoring is also considerably
reduced.
The most common inhalational agent in use in
many locations is still halothane, with isourane
as a secondary agent. Sevourane is starting to be
introduced as a result of reduction in its cost and
its utility for inhalational induction. The reduction in agent use (and cost) with semi-closed circle systems is useful, however only if a constant
supply of active soda lime is available. The common response to a lack of soda lime is to increase
gas ows to ensure removal of carbon dioxide;
this can then result in excessive use of available
oxygen. Vaporizers are infrequently calibrated
and output inaccurate. Appropriate adjustments
for vapor pressure and output will need to be considered inlocations signicantly above sea level.
The most common circuit conguration for
patients under 10 kg in these locations is the
Mapleson F, Ayres T piece, and familiarity with
this circuit would be essential for any anesthesiologist working with children in a low-resource
setting.
Anesthesia Supplies/Equipment,
Monitoring, andMedications
The availability of a seemingly endless supply of
consumables is restricted to very few, well
resourced, areas of the world; the situation in the
world of LMICs can be very different.
Reprocessing or cleaning for reuse devices that
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are made to be disposable in HICs is a most common scenario. As such the anesthesiologist (and
surgeon) should ensure an understanding of the
cleaning processes available in a particular location. It is possible that some form of autoclave or
chemical sterilization will be available, but this is
not assured.
One of the most common causes of medical
equipment failure in low-resource situations is
the lack of any planned, routine maintenance.
Most LMIC hospitals do not have readily available and competent technical support personnel.
Equipment is likely to be donated from multiple
sources, it may be “refurbished,” may not have
had maintenance manuals supplied, and spare
parts are likely unavailable. It is common in wellresourced hospitals to have equipment redundancy; if an anesthesia machine or monitor fails
to operate properly it is removed from the clinical
arena and replaced while it is quite likely repaired.
When a hospital does not have this redundancy,
the equipment often continues in service with
minor fault conditions, which can of course suddenly become more serious or total.
The need for specic amounts of anesthesia
supplies and drugs depends on the nature and
variety of surgical procedures planned or anticipated, but there are basic, essential needs that
almost all operating rooms and surgical missions
will require. Some missions, especially for orthopedic or gynecologic surgery, may involve procedures that will be performed under regional
(spinal or peripheral nerve block) anesthesia, and
thus sufcient equipment (needles, sterile kits, or
the ability to properly sterilize equipment) and
drugs (local anesthetics and perhaps adjuvants)
will need to be secured, while sedatives and general anesthesia drugs and equipment, while necessary, will be needed in much less volume. If
local supplies of medications are to be used, it
must be realized that shortages and limited availability are common. Some sources of drugs in
LMICs are not reliable as far as the actual concentrations and efcacy of the drugs supplied,
and unfamiliar medications (or names) may be
present in place of more familiar ones. Here
again, exibility, a good reference source, as well
as attention to the possibility of failure to see the
expected drug response on occasion, is
warranted.
As noted above, it is impossible to dene the
proper amount of or specic medications that
will be needed on any given surgical missions
because of the signicant differences that depend
on the nature of the expected procedures. In fact,
patients may be asked to supply medications for
their surgical procedure The World Health
Organization (WHO) has published and continuously updated a list of “Essential Medications”
that should be available in health facilities worldwide [7]. While this list is still somewhat aspirational for many locales, it is a good starting point
to assess how far any given facility or country is
from achieving a reasonable inventory of medications. A listing of anesthetic and other perioperative medications, excerpted from the entire WHO
list may be useful. We have not included antibiotics (again an availability issue) or other very specialized medications that might be needed for
specic procedures or patient populations, but
this list can serve as a checklist to assess whether
the needed medications will be available for most
intraoperative and perioperative situations.
Accustomed to monitoring the anesthetized
patient with a full set of vital signs and ventilator/
gas data, the practitioners will also experience
the limited capacity to monitor LMIC patients.
WHO and the World Federation of Societies of
Anesthesiologists have recommended minimum
guidelines for safe surgical practice but LMICs
are unable to meet them, with the possible exception of monitoring O2 saturation [8].
Blood Products
The source and availability of blood products
may be dependent on location and often governed by strict national protocols. Visiting medical staff must make themselves aware of the
national rules. In most LMICs, especially in the
lower-resourced group of countries, blood products may be very difcult to obtain, and family
members or friends are often required to donate
blood in order for patients to receive blood (either
directly from them or from banked stores, if such
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R. Neighbour et al.
exist, with the concept being that the family
donation will maintain the stores). Final crossmatching may have to be done at the bedside.
Often the product available is whole blood, as
there may be no blood bank to separate the blood
into individual products. This is of course an
advantage in many cases, as fresh whole-blood
transfusion should usually eliminate the need for
separate coagulation factors (plasma, cryoprecipitate) to be administered. As with almost all
other aspects of perioperative care in LMICs,
there will be a wide variety of scenarios, and the
only consistent advice is to be aware of the conditions and constraints and to be prepared.
Summary
It is a daunting task to consider working in and
setting up a safe OR for anesthesia and surgery in
an LMIC or other resource-limited environment,
because there are so many ways that resources
can be limited compared to what practitioners are
used to in the developed world. Any of these limitations or deciencies may signicantly affect
the range of surgical procedures that can be
undertaken, and/or the safety or even feasibility
of any anesthetic or surgical techniques and
choices. One might even paraphrase Tolstoy’s
famous line about happy and unhappy families
and suggest that (“happy”) ORs in the developed
world are rather “all alike,” while those that in
under-resourced areas (“unhappy”) are all lacking resources “in their own way.”
References
1. Lee S, Onye A, Latif A. Emergency anesthe-
sia in resource-limited areas. Anesthesiol Clin.
2020;38(1):213–30.
2. Vo D, Cherian MN, Bianchi S, Noël L, Lundeg G,
Taqdeer A, etal. Anesthesia capacity in 22 low- and
middle- income countries. J Anesth Clin Res. 2012;
3:207. https://doi.org/10.4172/2155- 6148.1000207.
3. Meara JG, Leather AJ, Hagander L, Alkire BC, Alonso
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solutions for achieving health, welfare, and economic
development. Lancet. 2015;386(9993):569–624.
4. Kempthorne P, Morriss WW, Mellin-Olsen J, Gore-
Booth J.The WFSA global anesthesia workforce sur-
vey. Anesth Analg. 2017;125(3):981–90.
5. Howie SR, Ebruke BE, Gil M, Bradley B, Nyassi E,
Edmonds T, et al. The development and implemen-
tation of an oxygen treatment solution for health
facilities in low and middle-income countries. J Glob
Health. 2020;10(2):020425.
6. Vande Lune SA, Lantry JH, Mason PE, Skupski R, Toth
A, Zimmer D, et al. Universal anesthesia machine:
clinical application in an austere, resource-limited
environment. Mil Med. 2020;185(5–6):e550–e6.
7. WHO model list of essential medicines - 22nd list,
2021. https://www.who.int/publications/i/item/WHO-
MHP- HPS- EML- 2021.02. Accessed 23 April 2022.
8. Gelb AW, Morriss WW, Johnson W, Merry AF,
Abayadeera A, Belii N, et al. World Health
Organization-World Federation of Societies of
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2018;126(6):2047–55.
How toEstablish aTrauma
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andDisaster Response Service
inLow- andMiddle-Income
Countries, Including Sta,
Transportation, Testing, Triage,
Resuscitation Training,
andFacilities
EmnetTesfayeShimber
Few people plan to fail, they just fail to plan.
– Lee Whistler
14
Abbreviations
ATLS Advanced Trauma Life Support
BEC Basic Emergency Care
DMAT Disaster medical assistance teams
EMS Emergency medical service
EMT Emergency Medical Team
ER Emergency room
IMS Incident Management System
LMICs Low- and Middle-Income Countries
MCM Mass Casualty Management
VAC Vacuum-assisted closure
WHO World Health Organization
How ToEstablish aTrauma Disaster
Response Service
A disaster is an occurrence disrupting the normal
conditions of existence and causing a level of suffering that exceeds the capacity of adjustment of
the affected community. The normal functioning
of the health system is inadequate to manage the
E. T. Shimber (*)
Hawassa University School of Medicine,
Hawassa, Ethiopia
urgent and massive demands posed by disaster.
This requires, therefore, the use of a different
operating plan and approach than the usual management of individual emergent health issues [1].
Disaster management can be anticipated and
planned for based on previous trends and situational analysis or sometimes, unfortunately, cannot be anticipated. The sudden effect of a disaster
will be magnied in underprivileged settings,
especially in low- and middle-income countries
(LMICs) [2]. There is no uniform planning procedure because the hazard proles of each
country vary greatly. However, the presence of
fundamental concepts aids in problem detection
and mitigation. Differences in geography, infrastructure, economy, political climate, and emergency response systems can be used to explain
this variation [3].
Without appropriate planning for unexpected
emergency situations, hospital health systems
can easily become overwhelmed in their attempts
to provide care to many groups of patients simultaneously during a critical event. Limited
resources, a surge in demand for medical services, and the frequent disruption of communication and supply lines create a signicant barrier
to the provision of effective health care. To
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
M. A. Hardy, B. R. Hochman (eds.), Global Surgery, https://doi.org/10.1007/978-3-031-28127-3_14
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E. T. Shimber
enhance the readiness of all health facilities and
to cope with the challenges of a disaster, health
facilities need to be prepared to initiate fundamental priority action at the rst knowledge of a
disaster [4]. Disasters go through four stages:
mitigation, preparedness, response, and recovery.
Each stage requires careful planning and quick
execution. Finding potential risks, assessing vulnerabilities, and estimating the degree of damage
are the fundamental steps [2].
LMICs serve large populations with limited
number of trained staff and lack of resources. A
large proportion of the patient health burden in
LMICs consists of young persons who require
urgent trauma and emergency services. The relative paucity of specialized neuro-trauma, orthotrauma, and intensive care management services
in LMICs necessitates a well-organized and practiced plan for emergency disaster conditions that
may occur unexpectedly [2].
With the current resource and professional
personnel constriction and with an overwhelmed
health care system, maintenance of routine basic
services has remained the main focus of care.
During a disaster, an interruption of standard
communications or shortage of critical equipment and supplies can disrupt operations of
essential health facilities. There is also an unanticipated rise in the number of admissions which
alone can overwhelm any hospital beyond its
functional reserve. Preparedness and timely
action facilitate containment and effective and
safe management of the disasters as well as prevention of post-disaster consequences [5].
As part of disaster preparedness, disaster medical assistance teams (DMAT) or Emergency
Medical Team (EMT) need to be established as
part of most regional or national planning efforts.
The composition of the team should range from
various health professionals to support staff, and
include nurses, technicians, remen, policemen,
and social workers. The team works best during
preparation for anticipated critical incidents but
can also be very effective in emergency, unexpected situations, once it has learned how to work
together efciently. Training coverage ranges
from Basic Emergency Care (BEC) course to
Mass Casualty Management (MCM). The BEC
course is geared toward preparing medical providers on the frontline to recognize, evaluate and
treat life-threatening conditions and to be able to
triage effectively when necessary.
Trauma System
Trauma often involves injuries that affect anywhere from a few to a large number of individuals at the same time. Mass casualty is an incident
which frequently places the event beyond the
existing capacity of the health system. An event
which involves many casualties differs from mass
casualty in that it is represented by a variety of
cases which present at the same time but may not
exceed the capacity of an existing health system.
Trauma care is underrepresented and inadequate
in most of LMICs because of scarcity of sufciently trained professionals, lack of specialized
equipment and supplies, and insufcient preplanned organization at various levels of care to
be able to deliver the expected standard of care.
Lack of infrastructure and human and non-human
resources lead to signicant mortality and morbidity during both natural and man-made disasters [5]. Trauma care must begin at the scene of
injury in order to be most effective. A new concept in most African countries is that bystanders
or community rst-aid responders must be able
to and be trained to immediately initiate trauma
care on site [6]. This may be followed by
pre- hospital care by Emergency Medical Team
(EMT) which are frequently unavailable. As a
result of initial care by “amateurs”, victims of
trauma arrive to hospital (if transportation or
roads are available) without receiving competent
medical care in the golden hour of resuscitation
[7]. In hospitals in LMICs emergency rooms
(ER) trauma activation systems are not yet sufciently mature to allow any responsible physician
to treat the trauma patients successfully [8].
The primary objective of a trauma system is to
eliminate the risk of death or permanent disability following traumatic events. Unfortunately, in
many developing countries, a trauma system is
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