The need for guidelines for common disabling conditions in natural disasters: ISPRM’s Rehabilitation Disaster Relief Subcommittee approach for guideline preparation

Aydan Oral, MDIstanbul University, Istanbul Faculty of MedicineDepartment of Physical Medicine and RehabilitationIstanbul, TURKEY

Background Natural disasters come without

warning May cause disabling traumatic

injuries in a considerable number of affected populations

There are scarce medical resources

The ability of health professionals to adhere to conventional standards of care could be greatly comprimised

Types of natural disasters

Meteorological

HurricaneBlizzardHeat/cold wave

Geological

EarthquakeVolcanic eruptionFlood

OtherFireExplosionDisease outbreak

Huntington MK, Gavagan TF. Disaster medicine training in family medicine: a review of the evidence. Fam Med. 2011;43(1):13-20.

Physiatrists’ role in disasters

Gosney JE Jr. Physical medicine and rehabilitation: critical role in disaster response. Disaster Med Public Health Prep. 2010;4(2):110-2.

The scope of the problem Patients in rehabilitation services: 59,578

in 20 clinics throughout Haiti Gorry C. Once the earth stood still (part I): Cuban rehabilitation services in Haiti. MEDICC Rev. 2010;12(2):44-7.

6000 to 8000 people had lost limbs or digits in Haiti Kelly JD. Haitian amputees--lessons learned from Sierra Leone. N Engl J Med. 2010;362(11):e42

ISPRM-RDRC

Rehabilitation Disaster Relief (Sub-) Committee (RDRC) of the International Society of Physical and Rehabilitation Medicine (ISPRM) aimed to provide guidelines for rehabilitation following disasters for common disabling conditions as one of its strategic goals

The action plan Phase 1 Searching for already available

guidelines Decision making on which guidelines

to prepare, adapt, or adopt Deciding on the experts who will be

reviewing/preparing specific guidelines

The action plan Phase 2 The review of existing guidelines Identification of needs to change

from normal standards to disaster standards

Producing required guidelines for specific health conditions if no standard guidelines are available

The health conditions for which specific guidelines should be prepared by the Disaster Relief Subcommittee

Guidelines should be prepared for SCI, TBI, and Amputees (unanimous agreement)

Guidelines for fracture/polytrauma and burn injuries

Pediatric trauma and pain management Rehabilitation needs of displaced

persons who have a pre-disaster disability

Earthquake Related InjuriesInjured Body Regions

%

Lower extremity Fracture Soft tissue injury

36.2 68.9 31.1

Head and neck Fracture Soft tissue injury

13.6 34.0 66.0

Spinal column and cord Fracture Soft tissue injury

12.0 67.3 32.7

Upper extremity FractureSoft tissue injury

11.3 59.0 41.0

FaceFractureSoft tissue injury

10.3 90.0 10.0

Mohebbi HA, Mehrvarz S, Saghafinia M, Rezaei Y, Towliat Kashani SM, Moussavi Naeeni SM, Motamedi MHK, Hoseini SH, Moharamzad Y: Earthquake related injuries: Assessment of 854 victims of the 2003 Bam disaster transported to tertiary referral hospitals. Prehospital Disast Med 2008;23(6):510–515.

Surgical interventions

%

Extremity amputation

10.8

Neurosurgical

6.5

Earthquake Related Injuries

Diagnoses for injured patients

%

Fracture/Dislocation

54.3

Wound infections/Abscess

37.0

Crush injury 25.3Head/Face/Brain injury

9.3

Burn 1.9Other 42.6

The 7.0-magnitude earthquake in Haiti on January 12, 2010,

The most common injury-related surgical procedures were wound debridement/skin grafting, treatment for orthopedic trauma, and surgical amputation

Centers for Disease Control and Prevention (CDC). Post-earthquake injuries treated at a field hospital- Haiti, 2010.MMWR Morb Mortal Wkly Rep. 2011;59(51):1673-7.

Earthquake Related InjuriesInjuries %Extremity fractures

61.15

Thoracic injury 29.57Spinal injury 24.98Pelvic fractures

17.04

Head injury 7.60Facial fractures

3.43

Abdominal injury

2.51Dong ZH, Yang ZG, Chu ZG, Chen TW, Bai HL, Shao H, Tang SS, Denor JC. Earthquake-related injuries: Evaluation with multidetector computed tomography and digital radiography of 1491 patients. J Crit Care. 2011 Apr 20. doi:10.1016/j.jcrc.2011.03.007

The 8.0 magnitude Sichuan earthquake in China, at 2:28 pm Beijing time on May 12, 2008

Hurricane Related PM&R ConditionsPM&R conditions %Swollen feet or legs

26.36

Leg pain and cramps

20.92

Headache 15.06Neck and back pain

12.55

Skin ulcer 6.28Fracture 5.86Musculoskeletal arm problem

5.44

Neuropathic 5.02Musculoskeletal leg problem

4.18

Stroke 2.51Bursitis 2.09SCI 1.67Amputee 1.26

Chiou-Tan FY, Bloodworth DM, Kass JS, Li X, Gavagan TF, Mattox K, Rintala DH. Physical medicine and rehabilitation conditions in the Astrodome clinic after hurricane Katrina. Am J Phys Med Rehabil. 2007;86(9):762-9.

Any rehabilitation guidelines for disaster response?No specific guidelines (those

specifically prepared for field response in disasters) are reported to be available

Action Searching the internet for

appropriate guidelines, which have already been written and disseminated which may be adopted or adapted

LIST OF AVAILABLE GUIDELINES

SCI Guidelines for the Management of Acute Cervical Spine and

Spinal Cord Injuries. Association of Neurological Surgeons (AANS) / Congress of Neurological Surgeons (CNS)

Early acute management in adults with spinal cord injury: a clinical practice guideline for health-care professionals. 2008 May. NGC:007157. Consortium for Spinal Cord Medicine; Paralyzed Veterans of America

Preservation of upper limb function following spinal cord injury: a clinical practice guideline for health-care professionals. 2005 Apr. NGC:004300. Consortium for Spinal Cord Medicine

Pressure ulcer prevention and treatment following spinal cord injury. 2000 Aug (reviewed 2005). NGC:001815. Consortium for Spinal Cord Medicine; Paralyzed Veterans of America

LIST OF AVAILABLE GUIDELINES

TBI Guidelines for Prehospital Management of Traumatic Brain Injury 2007. Brain Trauma

Foundation Traumatic brain injury: diagnosis, acute management and rehabilitation. 2006 Jul.

NGC:005397. New Zealand Guidelines Group VA/DoD clinical practice guideline for management of concussion/mild traumatic

brain injury. 2009 Apr. NGC:007713 Department of Defense - Federal Government Agency [U.S.]; Department of Veterans Affairs - Federal Government Agency [U.S.]; Veterans Health Administration

Guidelines for Acute Medical Management of Severe Traumatic Brain Injury in Infants, Children, and Adolescents A Supplement to Pediatric Critical Care Medicine: Brain Trauma Foundation

Guidelines for the field management of combat-related head trauma. Triage and transport decisions. 2005. NGC:005790. Brain Trauma Foundation

Head injury. Triage, assessment, investigation and early management of head injury in infants, children and adults. 2007 Sept. NGC:005953. National Collaborating Centre for Acute Care

Guidelines for the field management of combat-related head trauma. Treatment: pain management and the use of analgesics for sedation. 2005. NGC:005788. Brain Trauma Foundation

LIST OF AVAILABLE GUIDELINES AMPUTATION VA/DoD Clinical practice guideline for

rehabilitation of lower limb amputation Evidence Based Clinical Guidelines for the

Physiotherapy Management of Adults with Lower Limb Prostheses. British Association of Chartered Physiotherapists in Amputation Rehabilitation, 2003

Amputation - Medical Disability Guidelines

LIST OF AVAILABLE GUIDELINES WOUNDS All you need to know about wound care.

WOUND HEALING ASSOCIATION OF SOUTHERN AFRICA

LIST OF AVAILABLE GUIDELINES BURN INJURY Management of Burns. World Health

Organization ABA White Paper: Surgical Management

of the Burn Wound and Use of Skin Substitutes

2001 Practice Guidelines for Burn Care. American Burn Association (ABA)

LIST OF AVAILABLE GUIDELINES POLYTRAUMA and FRACTURES Practice management guideline for pulmonary contusion -

flail chest. 2006 Jun. NGC:005352 Eastern Association for the Surgery of Trauma ACR Appropriateness Criteria® suspected lower urinary

tract trauma. 1996 (revised 2009). NGC:007808. American College of Radiology

Renal trauma. In: Guidelines on urological trauma. 2009 Mar. NGC:007328. European Association of Urology

ACR Appropriateness Criteria® rib fractures. 1995 (revised 2008). NGC:007014.American College of Radiology

Evaluating infants and young children with multiple fractures. 2006 Sep. NGC:005253. American Academy of Pediatrics

LIST OF AVAILABLE GUIDELINES PAIN Clinical Guidelines for the Use of

Chronic Opioid Therapy in Chronic Noncancer Pain. The Journal of Pain, Vol 10, No 2 (February), 2009: pp 113-130.

Next step The next step will be the reviewing

process of available standard guidelines by a group of experts on each disabling health condition, which will eventualy lead to ISPRM guidelines for rehabilitation following natural disasters

Experts suggested for the preparation of Guidelines on Specific Health Conditions

Health Conditions

Suggested experts

SCI Anthony Chiodo (USA), Stieve Stiens (USA), Jianan Li (China), Farooq Rathore (Pakistan), Colleen O’Connell (Canada), James Guest (neurosurgeon) (USA), Peter Wing (Orthopedic Surgeon)( member of the ISCoS group)(Canada), Michael Baumberger ( Switzerland), Apichana Kovhinda (Thailand), Dirk van Kuppevelt (the Netherlands), Kazadi Kalangu (Zimbabwe)

TBI Faye Tan (USA), Steven Flanagan (USA), Nathan Zasler (USA), Kazadi Kalangu, A Chingono, James January (Zimbabwe),

Polytrauma and Fractures

Mary Catherine Spires (USA)

Amputees Alberto Esquenazi (USA), Jim Gosney (USA), Anthony Redmond (UK), Colleen O’Connell ( Canada), Al Ingersoll (prosthetist)(USA), Jan Geertzen (the Netherlands), Carolina Schiappacasse (Argentina)

Burn injuries

Peter Esselman (USA), Steven Fisher (USA)

Nerve injuries

Jacquelline Wertsch (USA), Andrew Haig (USA)

Pediatric trauma

Deborah Gaebler Spira (USA)

Other suggestionsGeneral Because field responder level guidelines seem underrepresented,

it is advised that individual PRM national societies should also be surveyed for guidelines which are focused primarily on field response.

To solicit national society input, this issue could be raised at the NEWS & VIEWS of the ISPRM.

We should work closely with the Global Initiative for Emergency and Essential Surgical Care (GIEESC) at WHO regarding guidelines.

The guideline panel should include experts from different disciplines to enhance the value of guidelines

A consensus should be reached before hand on where these guidelines will be submitted for publication

Other suggestionsFormat of the guidelines Guidelines for different conditions

should in the same format to ensure consistency among guidelines.

Guidelines should be with illustrations for being easily understood by others whose native language is not English

Vulnerable populations Children National Commission on Children and

Disasters. 2010 Report to the President and Congress. AHRQ Publication No. 10-M037. Rockville, MD: Agency for Healthcare. Research and Quality. October 2010.

The elderly Persons with disabilities

Obstacles Lack of guidance or training for

physicians on how to function in disasters

Not a clear definition of which actions are ethically justified during a crisis

Inadequate liability protections for health professionals who may have to place some patients' needs ahead of others in crisis situations

IOM Report. Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations. September 24, 2009. http://www.iom.edu/Reports/2009/DisasterCareStandards.aspx

Conclusion There is a clear need for rehabilitation

guidelines for specific health conditions encountered in natural disasters

ISPRM RDRC will be doing a very important work that would meet the needs of injuried persons in natural disasters

Thank you for your attention