Emergency Medicine In The Developing World 2011 (Part 3)

• Extensive training and acclimatisation in ice pools (in fish refrigerator)
• Full ALS kit taken, but this is questionable if there is not excellent backup
• Severe gastro from the local water (Rx cipro & metronidazole) for the foreigners
• Mind-set is exceptionally important for acclimatisation
• Multiple strategies for dealing with acute mountain sickness (AMS)
• Insight of guides very valuable
• Diamox only after symptom onset (125mg BD)
• Dehydration leads very rapidly to illness
• Dryness and dust a problem above the treeline
• Very rapid changes in weather at high altitude
• Trekking poles ubiquitous
• Telemetric thermometer – measuring “pill” with transmitter to handheld device.
• One medevac – ankle ligamentous injury
• Anticipatory thermogenesis – Lewis Pugh can raise his body temperature in anticipation of a swim to about 38.4 degrees C through mental preparation
• Test swim a complete failure – usual aggressive tactic failed through hypoxia
• Telemetric temperature dropped to 35 degrees during swim
• “Sauna Tent” used to warm swimmer after swim
• Water temp around 5 degrees
• Medical conditions on the trip: altitude sickness, gastroenteritis, hypothermia, ankle sprains, conjunctivitis (irritant from dust), LRTI, conjunctivitis, facial cellulitis, sun exposure, rash.

• The busiest of our wilderness areas is right in the middle of the city – Table Mountain
• Lack of appreciation for the rapidly changing weather conditions is a key cause of wilderness injury and illness even in our more ‘benign’ context
• Vehicular accidents in mountain passes are a common source of ‘wilderness’ rescues
• 20 years ago it took around 18 hours to reach, access, treat, carry and belay a patient off the mountain to definitive care. The focus was on the mountaineering required.
• The advent of regular use of helicopters changed the focus; more critically ill patients were reached in time, and the medical treatment of the patient has become paramount.
• An unforeseen consequence of this has been the decline of ground missions and thereby the deterioration of skills.
• The other technological revolution in Search and Rescue has been the use of the cell-phone – lost walkers can be “talked off the mountain”, or National Parks rangers can be dispatched to walk them off the mountain. GPS-equipped phones now enable dispatch directly to co-ordinates of injured patients.
• Suicide remains the highest proportion of fatal injuries.
• Other key areas are search, technical rescue, logistics, communications, etc.

• Hypothermia: Accidental or Intentional; Primary or Secondary

• Accidental hypothermia – cold water immersion, cold weather sports, stranded motorists, intoxication, etc
• Intentional hypothermia – therapeutic and neuroprotective. Cardiac arrest, heart, head and spinal cord surgery, anaesthesia, etc
• Secondary hypothermia: sepsis, trauma, uremia, drugs (beta-blockers, clonidine, merepidine, neuroleptics, general anaesthetics), etc

• Mild (32-35), Moderate (30-32), Severe (<30)
• Temperature regulation: thalamic control, physical factors (conduction, convection, radiation, evaporation)
• Sequalae: refractory bradycardia, J or Osbourne waves, decreased LOC, shivering, diuresis
• Prehospital management: dry, warm environment, heat packs to axilla and groin, etc
• Dysrhythmias: atropine, lignocaine, pacing, defib ineffective below 30C
• Perfusing rhythm: external warming, warm infusion, monitor
• Non-perfusing rhythm: CPR with invasive warming. <30C: single defib if VF/VT, hold medications, focus on active warming. 30-34: defib as needed, double time between medications, continue warming. >34: follow normal protocols, continue warming.
• IV warm normal saline – 42-45C (use a microwave with a predetermined fluid chart)
• Warmed humidified O2 (intubation may be required)
• Bladder and pleural lavage with warm NS
• Monitor K+ and glucose
• A-V continuous counter-current lavage if available
• Complications: sepsis, aspiration, pulmonary oedema, rhabdomyolysis, arrhythmia, renal failure, seizure, neurological deficit
• Beware afterdrop
• See “Accidental Hypothermia….” Van der Ploeg et al, Resuscitation, 2010
• Frostbite: soft tissue injury through freeze-warming cycle (more complex than just freezing of tissue)
• Treatment of frostbite – rewarming, fluid rehydration, prophylactic antibiotics (controversial!), tetanus toxoid, analgesia
• “Trench foot” – non-freezing, immersion injury

• Famine affecting 13 million people on the background of a civil war spanning 20 years.
• World Food Programme has withdrawn support to much of the region due to militant activities. Death rate now 7 per 10 000 per day.
• Gift of the Givers Foundation is now the largest humanitarian organisation in Africa
• 11 flights, 4 feeding and medical centres established
• An improvement in mortality rates has been seen in the limited areas to which assistance has been given
• Operating services were established with equipment flown in from SA
• Key medical functions established by the team – obstetric, paediatric, general medicine, orthopaedics, surgery
• True focus of disaster intervention should be on recovery and rebuilding services

• Growing sporting phenomenon
• Ice Swimming Association – promoting the sport, encouraging research, exploring the unknown (and finding new places to swim)
• Swim only in speedo, cap and goggles (no wetsuits)
• Definition of an ice swim: 1 mile in Fraserberg Speedo Ice Swim in midwinter in SA. Endurance swim = 600m, Ice swim = 1 mile
• Screening process: Robben Island Swimmers, then Silvermine training (8-10 degrees for 20 minutes)
• I&J (Fish) Factory ice baths – 5 min for endurance swim, 10 minutes for the mile
• Pre-swim medicals including ECGs – often very “abnormal” baseline in fit individuals!
• Entire medical setup (including mobile ICU kit) taken to Fraserberg (no significant local resources)
• Heated medical tent (gas heaters), doctor with lifeguards on water and another in tent, stretcher for every swimmer.
• Buddy system for swimmers, boats, canoes and stand-up paddlers as backup.
• Exit assistance on coming out the water (orthostatic hypotension prevalent on exit)
• Rescue diver and swift-water rescuers on the water
• Pre-swim marking of veins in case of later need of IV access
• All swimmers exit to tent
• Electric heaters better than gas, but power is a problem
• Tympanic temperatures used for routine measurements, rectal for patients in extremis
• Afterdrop clinically relevant in ALL patients, but temperature measurements 10 minutes apart didn’t show this clearly
• Most exited with GCS14-15 (difficulty speaking)
• Skin hyperaemia common
• The greatest discomfort for the swimmers is in the rewarming process
• Dam temperatures 4.5-4.9C
• Average time in the water 28’ (23-35 min range)
• Mean exit temperature (tympanic) 30.2 (range 25.8-33.9)
• Mean recovery time 42 minutes
• Knowing the true difference and pattern of variation between tympanic and core temperature would be very helpful.

• Sense of passion, energy and commitment is palpable in the emergency medicine fraternity
• Personal memories of the beginnings of the HIV epidemic

• Before the HIV epidemic, we had _no_ effective antiviral therapy
• In the space of three decades, we have developed effective treatments, and have discovered cures to some other illnesses along the way (cf. Hep C)
• PEPFAR alone is now providing treatment to more than 3.5 million people today
• The fact that it took so long is also a legacy…

• Bush tasked O’Neal with finding a solution to the African AIDS epidemic… initially he requested 15 billion USD
• This was granted and passed into law in less than 5 months – a victory for passion and drive
• Lessons:

• Get tough on disease…or die
• Soft diplomacy works (focus on service)
• Health system strengthening is essential to providing anything more than episodic assistance.

• St Francis: “Start by doing what is necessary, then what is possible, and soon you will be doing the impossible.”
• Think differently about emergency medicine: think in terms of acute care
• Political leadership needs to be educated on health issues

• “I would like to live life like a river, carried by the surprise of its own unfolding.”
• What does it mean to be human?
• Six values of humanity:

• Temperance
• Courage
• Wisdom/knowledge
• Love/compassion
• Justice
• Transcendence

• We can view the world in reality or as special or hurt children… and we all change our view based on our mood/experience
• Start NURSEing yourself:

• Nutrition – eat good food
• Understanding – find people who can understand and empathise with you
• Relaxation – take the time to refresh
• Spirituality – go out and seek the good in life
• Exercise – but have fun doing it

• To be a good ER doc, think of ER DOC:

• Emotional orientation – recognise that patients arrive in emotional insecurity
• Right brain – engage with the patient’s eyes, use body language, listen.
• Digits on the patient
• Other patient (the family in the waiting room)
• Collegiality

• One of the greatest human needs is to have emotional validation

• “…a specialist technical rescue capability…”
• USAR = natural (eg. earthquake) vs technological (eg. terrorist incident)
• 5 key components: management, logistics, search, rescue, medical
• INSARAG – International (Urban) Search and Rescue Advisory Group
• Total number of patients rescued/managed by USAR is very small compared to the number of teams deployed (almost no live saved except for Haiti)
• Cost to save a life in Haiti from USAR perspective 100x greater than a medical/surgical team deployed to the same disaster (GBP 250 000 vs GBP 2500)
• However, can we compare the cost of a fire department to a hospital? Does it make sense to compare USAR to medical response?
• Role of USAR:

• Save lives
• Support the affected country -> body recoveries
• “Beyond the Rubble” – Haiti has taught us that we need to be more involved in infrastructure assessments and recreation, re-establishing services, and supporting medical services.
• Augmentation of existing emergency services
• Limiting the period of time that the focus remains on the possibility of finding viable survivors through a very competent search function

• Disasters are becoming more complex – 50% urban, increased reliance on technology, increased population density, etc
• Four principles of humanitarian response: Humanity, Neutrality, Impartiality, Operational Independence
• Medical response – embedded or added

• One study revealed that 1.6 rescuers died for every victim saved
• No current international consensus on medical training for USAR teams
• INSARAG guidelines are not an authoritative instruction, but rather a recommendation
• Preparedness is an important mandate
• Medical component of INSARAG guidelines: provide care to USAR team members, care for victims encountered during the efforts, and care for search dogs.
• UK selection process explained – good standard, including requirement for EM/ATLS/PHTLS for all team members
• Regular clinical competence training
• Deployment of the pregnant woman where there is radiation risk:

• Two types of risk – deterministic (foetal death, malformation and mental retardation. Threshold is 100mGy) and stochastic (ie. Cancer) risk. For every mGy the foetus receives is a 6 in 10 000 increase in risk of malignancy (ie. 25x greater risk than normal foetus).
• Pre-deployment urine testing for female team members is thus advised

• Review of national disaster competencies

• Hundreds! They lack consensus and clarity
• Crossover of terminology, roles and functions

• Challenges to developing competencies – disasters occur infrequently; conditions tend to be worse in poor countries; multiple professions are involved; multiple roles and tasks are required.
• Mental health preparation is important
• Potential recommendations:

• International training course
• Detailed medical competencies
• Programme governance
• International collaboration
• International certification by INSARAG
• Framework for regulation
• Peer review

• Haiti – sentinel event in disaster response medical ethics
• Levels of response:

• 1 – daily work
• 2 – mass casualty (within normal frame of reference)
• 3 – disaster (completely different environment)

• We must define what is acceptable and what is unacceptable within the framework of the disaster setting. Drawing this line is a challenge.
• Ethical management of large numbers of bodies (taking into account forensic needs) can be difficult.
• Beware the “CNN effect” … and the “VIP/Politician effect”
• Cf. International Red Cross/Red Crescent guidelines for humanitarian aid, and especially the code of conduct (492 organisations have committed to these values).
• The focus shifts quickly from disaster medicine to the provision of normal medical services (communicable disease, chronic disease, obstetric services, mental health services, etc) in an area without services due to disaster damage.
• Keep the focus at all times on the beneficiaries of care
• The most challenging decision is when to do nothing.

• “Hey Doc… do you think anyone could still be alive in there?”
• Relevance:

• Accountability for the missing can be hard to obtain
• All communities expect some level of effort directed at SAR
• SAR does ‘compete’ with other priorities
• Ending the SAR phase can be a difficult decision

• The decision to terminate SAR efforts is usually made by the politicians, but they need input from our services
• The level of available data is extremely poor
• Prior thoughts: Golden 48 hours (based on limited data); Rule of Fours (anecdotal)
• Medical literature: Most collected retrospectively; hospital based parameters; sometimes difficult to determine if the patient was even entrapped in the first place.
• Almost no studies examine factors contributing to survival
• The media is beginning to do a very good job of documenting what we are doing, but details are often highly variable and difficult to assess
• Sample data points:

• Tangshan (1976): 13 days
• Armenia (1998): 13-19 days ?
• Phillippines (1990): 14 days (meticulously confirmed)

• Data published in 2006 – 18 earthquakes from 1985-2003. Examined factors influencing survival; study not completed as well as the authors would have liked.
• Several late rescues – max day 14, but 50% by day 5/6.
• Challenges with data:

• “Crawl back” phenomena – people trapped in secondary collapses after venturing back into the rubble can cause false expectations
• Misapplication of the data – 14 days being regarded as an “absolute” limit (cf. Haiti at Hotel Montana).

• New research:2010-2011

• Re-examination of the data
• Included engineering literature
• Findings – majority of rescues done by 5-6 days
• Limited medical data
• Questions are often tied to structure type

• Examples of potential factors influencing survivability:

• Victim injuries
• Victim pre-existing conditions
• Survivor behaviour
• Micro-climate (air, temperature, ability to move)
• Access to food/water (many fascinating anecdotes)
• Availability of medical care during/after extraction (NB crush syndrome, infections, delayed management of traumatic injuries, etc)
• Structure tendency to form voids (only factor which carries significant evidence)

• Age does NOT seem to be a factor that affects survival (many infants and elderly rescued)
• Void space formation:

• Biggest determinant of survival
• Construction of buildings makes the biggest difference
• Location in the structure plays a role as well

• USAR community strategy: Occupancy of structure and potential for void space formation
• Summary:

• All communities expect an effort
• There is no universal time constant
• Void space formation is the strongest predictor of survival (with other factors considered where appropriate)

• Implications:

• Multidisciplinary approach to formulating an answer (engineering/medical/SAR/etc)
• SAR strategy should not be based on a time constant
• Phased approach rather than all-or-nothing
• Guidance to the authorities/media must be presented in an understandable fashion.
• Data collection must continue and improve

• Prizes, thanks, etc.
• AFEM’s first congress next year – 30 Oct-1 Nov 2012 – www.afcem2012.com
• African Journal of Emergency Medicine – AFJEM – www.afjem.com – keenly soliciting submissions; active author assistance program.