Article

Operative care after the Haiti 2010 earthquake: implications for post-disaster definitive care

Correspondence 429

needed to establish the cost-effectiveness of procalcitonin. Therefore, if procalcitonin level can guide antibiotic use and be valuable in predicting mortality and CAP severity, using its level at the ED may be acceptable.

Jeong Ho Park MD Seung Pill Choi MD, PhD Jung Hee Wee MD

Department of Emergency Medicine

College of Medicine The Catholic University of Korea

Seoul, Korea E-mail address: [email protected]

http://dx.doi.org/10.1016/j.ajem.2012.10.007

References

  1. Park JH, Wee JH, Choi SP, Oh SH. The value of procalcitonin level in community-acquired pneumonia in the ED. Am J Emerg Med 2012;30: 1248-54.
  2. Schuetz P, Muller B, Christ-Crain M, Stolz D, et al. Procalcitonin to initiate or discontinue antibiotics in acute respiratory tract infections. Cochrane Database Syst Rev 2012;9:CD007498.

Operative care after the Haiti 2010 earthquake: implications for post-disaster definitive care

To the Editor,

On January 12, 2010, a 7.0 earthquake struck Haiti, affecting 3 million people and causing 220000 deaths and more than 300000 injuries [1]. In response to a request from Hopital Saint Francois de Sales in Port-au-Prince, a series of surgical teams were deployed from the Shock Trauma Center at the University of Maryland Medical Center (STC-UMMC) to operate 2 Operating rooms and provide postoperative care. The STC-UMMC teams operated alongside the staff of Hopital Saint Francois de Sales from January 30 through June 27, 2010. After reviewing the teams’ operative records and reports of other foreign medical teams (FMTs) responding the Haiti earthquake (see Table and Fig.), we have explored the potential implications of these experiences regarding Disaster preparedness and FMT response.

Although the injury pattern of the Haiti 2010 earthquake closely resembled that seen after other recent disasters [2,3], foreign medical and surgical support teams were engaged in the treatment of traumatic injuries in Haiti for a substantially longer period than previously recognized [2,4]. In Haiti, STC-UMMC and other FMTs were fully occupied with the treatment of traumatic injuries for 6 weeks after the disaster [4]. STC-UMMC performED operations treating solely fractures and wounds for the initial six weeks. After this point, STC-UMMC continued to treat predominantly soft tissue and orthopedic injuries. Although the cause of injury

was not listed in operative reports, the vast majority of these injuries were reported to be earthquake-related.

A number of factors likely contributed to this prolonged role of the FMTs: roadway damage delayed patients’ access to care, widespread confusion persisted regarding the availability of treatment facilities, limited relative capacity for patient evacuation, and local residents’ hesitation to seek treatment from FMTs [5]. Likely the most significant reason for a prolonged FMT presence was that local health care services were extremely limited before and after the earthquake. Haiti is the most impoverished country in the western hemisphere with some of the poorest public health indictors in the region, and the limited health services that were available in Haiti were devastated by the earthquake [1,6]. There existed a limitED capacity to transition care back to non-functioning or impaired local health care counterparts. FMTs also became responsible for much of the long-term surgical care typically required for the high incidence of non-union, mal-union, and postoperative infection following disaster-related surgery for musculoskel- etal injury [2,5]. Additionally, in the experience of the authors, patients with chronic and non-emergent complaints presented for evaluation and treatment from Week 3 onward, because free health care was available from the FMTs. Eventually a dual system emerged with the Haitian providers managing routine care and STC-UMMC or other FMTs maintaining their focus on the trauma and surgical patient. Still, FMTs’ exit strategies were significantly complicated by the ongoing demand and need for their services.

This experience emphasizes the need for more focused and

stronger programs to build local acute care capacity and strengthen surgical systems at the national level. Such programs would function to enable a more expedient transition of care to local providers following a disaster response. These would serve as a fundamental mechanism for disaster preparedness. Additionally, the experience of STC-UMMC highlights the importance of FMTs leveraging local partner- ships. FMT coordination with local partners, as seen in the STC-UMMC response, limits many of the hazards observed in prior long-term disaster response efforts, such as creating a new health-gap or inattentiveness to local concerns.

The Guidelines for the Use of Foreign Field Hospitals in the Aftermath of Sudden-Impact Disasters state that foreign field hospitals (FFHs) be established within 24 hours after a disaster and that FMTs operate them for up to 15 days, unless otherwise requested by local authorities [7]. In the aftermath of the earthquake in Haiti though, the need for FMTs with surgical capacity continued far beyond 15 days. Cooperating with local health care providers, international medical and surgical teams treated high volumes of patients in temporary field hospitals and surviving medical facilities for up to 6 months and longer after the earthquake [4]. It has been suggested that the 15-day exit guideline for FFHs should be revised to better reftect local context and needs, as well as the diverse modalities of health disaster responders [3,8,9]. This aspect of FMT efforts in disaster response is the subject of much discussion, and further study is needed to elucidate the appropriate exit strategy for

430 Correspondence

Table Procedures performed by week and type during STC-UMMC operations in Haiti, January 30 through March 25, 2010 a

Internal fracture treatment

External fracture treatment

Wound care

Amputation

Extraneous

Week 3

1

4

9

0

0

Week 4

12

9

22

1

0

Week 5

12

9

21

0

0

Week 6

14

2

15

3

0

Week 7

13

3

4

2

10

Week 8

19

1

5

0

13

Week 9

7

6

9

2

19

Week 10

6

6

11

1

14

Week 11

4

2

9

0

6

Total

88

42

105

9

62

a STC-UMMC operations in Haiti began during week 3 post earthquake, so no data is provided for Week 1 and Week 2. Data reviewed for initial 2 months of operations.

Fig. Procedures performed by week and type during STC-UMMC operations in Haiti, January 30 through March 25, 2010 (weeks 3-11).

FMTs in such situations. The experience of STC-UMMC as well as the extended timeline realized by other FMTs in this particular response effort could potentially suggest a longer deployment period for FMTs than previously set for FFHs, but certainly supports a more context-specific end point.

On the whole, with an extended demand for international medical and surgical support in Haiti due to the limited baseline health care capacity and further complicated by the earthquake, the experience of STC-UMMC emphasizes the importance of national acute care capacity building as an essential component of emergency preparedness, the role of local partnerships in FMT response, and the need to further evaluate exit guidelines for FMTs in disaster response.

Lucas C. Carlson BA

University of Maryland School of Medicine

Baltimore, MD 21201, USA E-mail address: [email protected]

Jon Mark Hirshon MD, MPH, PhD National Study Center for Trauma and Emergency Medical Systems

University of Maryland School of Medicine

Baltimore, MD 21201, USA E-mail address: [email protected]

Emilie J.B. Calvello MD, MPH Department of Emergency Medicine University of Maryland School of Medicine

110 South Paca Street, 6th Floor, Baltimore MD 21201, USA

E-mail address: [email protected]

Andrew N. Pollak MD R Adams Cowley Shock Trauma Center University of Maryland Medical Center Baltimore, MD 21201, USA

E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2012.10.020

References

  1. Haiti: One Year Later, January 18, 2011. United Nations Office for the Coordination of Humanitarian Affairs Website. www.unocha.org/ issues-in-depth/haiti-one-year-later. Accessed March 14, 2012.
  2. Phalkey R, Reinhardt JD, Marx M. Injury epidemiology after the 2001 Gujarat earthquake in India: a retrospective analysis of injuries treated at a Rural hospital in the Kutch district immediately after the disaster. Glob Health Action 2011;4:7196.
  3. von Schreeb J, Riddez L, Samnegard H, Rosling H. Foreign field hospitals in the recent sudden-onset disasters in Iran, Haiti, Indonesia, and Pakistan. Prehosp Disaster Med 2008;23(2):144-53.

Correspondence 431

  1. Centers for Disease Control and Prevention. Post-earthquake injuries treated at a field hospital–Haiti, 2010. MMWR Morb Mortal Wkly Rep 2011;59(51):1673-7.
  2. Redmond AD, Mardel S, Taithe B, Calvot T, Gosney J, Duttine A, et al. A Qualitative and quantitative study of the surgical and rehabilitation response to the earthquake in Haiti, January 2010. Prehosp Disaster Med 2011;26(6):449-56.
  3. McIntyre T, Hughes CD, Pauyo T, Sullivan SR, Rogers Jr SO, Raymonville M, et al. Emergency surgical care delivery in post- earthquake Haiti: Partners in Health and Zanmi Lasante experience. World J Surg 2011;35(4):745-50.
  4. Department of Emergency and Humanitarian Action, the World Health Organization, Area on Emergency Preparedness and Disaster Relief, the Pan-American Health Organization. Guidelines for the use of foreign field hospitals in the aftermath of sudden-impact disaster. Prehosp Disaster Med 2003;18(4):278-90.
  5. de Ville de Goyet C. Editorial comments: surgery under extreme conditions in the aftermath of the 2010 Haiti earthquake. Prehosp Disaster Med 2011;25(6):494-5.
  6. Gerdin M, Wladis A, von Schreeb J. Foreign field hospitals after the 2010 Haiti earthquake: how good were we? Emerg Med J 2012 [Epub ahead of print].

Allergies to analgesic medications in ED patientsB,BB

To the Editor,

Analgesics are the most frequently used and prescribed medications in the emergency department (ED) [1]. However, little research has focused on analgesic allergies in an ED population [2]. In this study, we report the prevalence of self- reported analgesic allergies in an adult ED patient population as well as the characteristics of patients reporting allergies.

This study was a retrospective chart review design, reviewed and approved by the local institutional review board. The site was the ED of a tertiary care center with an annual adult census of approximately 60000 patients. The paper charts for adult (age >=18 years) ED visits for the period of February 2010 were requested for review; records were obtained from the department’s financial staff. Each chart had the following data abstracted: age, sex, ethnicity, and Analgesic drug allergies. Information on drug allergies is usually based on patient self-report. Opioids included were morphine, codeine, oxycodone, hydrocodone, hydromorphone, and fentanyl. For combination products (eg, Vicodin, Percocet, etc), the allergy was listed under the opioid ingredient. Nonsteroidal anti-inftammatory drugs (NSAIDs) included were ibuprofen, ketorolac, naproxen, and NSAID (unspeci- fied). Allergies were entered as NSAID (unspecified) if “NSAID” or “all NSAIDs” were the reported allergy or for an NSAID besides ibuprofen, ketorolac, or naproxen. Because the study’s focus was on medications likely to be ordered or prescribed by ED physicians as analgesics, acetaminophen

? External funding: The authors did not receive any external financial support for this study.

?? Conftict of interest: The authors have no financial confticts of

interest regarding the content of this study.

alone and aspirin were not included for analysis. Patients with multiple visits during the study period were considered to have an analgesic allergy if it was recorded on at least 1 visit. A supplemental electronic record was used to obtain data on disposition (discharged, admitted, expired).

Prevalence of analgesic allergy was reported as a proportion. Demographic data and disposition were com- pared using t test and ?2 analysis. Statistical calculations were performed using GraphPad InStat (GraphPad Software, Inc, La Jolla, CA). Statistical analyses used only unique patients identified during the study period; the exception was patient disposition, which analyzed all visits.

Records for 2988 nonconsecutive ED visits (2771 unique patients) were available for review. Among unique patients, 283 patients (10.2%; 95% confidence interval, 9.1%-11.4%) had a recorded opioid or NSAID analgesic allergy. A total of 2389 patients (86.2%) had no known drug allergies; 99 cases (3.6%) had no documentation of any drug allergy information. Seventy-four patients (26.1%) reported multiple analgesic allergies. Analgesic allergic patients were older than nonallergic patients (mean age, 47.9 vs 42.2 years; unpaired t test, P b .0001) and more likely to be female (67.8% vs 48.1%; ?2 test, P b .0001). Distribution of ethnic background did not significantly differ between groups (?2 test, P = .118). Allergic patients had a significantly higher rate of hospital admission or death at any given visit (26.9%) compared with nonallergic patients (16.7%) (?2 test, P b .0001) (Table 1). Three patient deaths were recorded in the collection period, all occurring in nonallergic subjects. Among 404 total reported allergies, codeine (105 patients) and hydrocodone (57 patients) were most frequent (Table 2). Opioids accounted for approximately 74% of analgesic allergies.

To our knowledge, this study is among the first to specifically examine the prevalence of analgesic allergies in

Table 1 Patient characteristics

Allergic Nonallergic Unadjusted odds patients patients ratio (95%

confidence interval)

n (% total) 283 (10.2) 2389 (86.2)

Mean age (SD) 47.9 (17.5) ? 42.2 (17.9)

Female patients, 192 (67.8) + 1148 (48.1) 2.28 (1.76-2.96) n (%)

Ethnicity, n (%) a

White 233 (82.3) 1758 (73.6)

Black/African 12 (4.2) 156 (6.5) American

Hispanic 36 (12.7) 379 (15.9)

Other 2 (0.7) 96 (4.0)

Admissions/ 88 (26.9) + 429 (16.7) 1.83 (1.40-2.39)

death, n (%)

a No significant group differences by ?2 test.

* P b .0001, unpaired t test.

+ P b .0001, ?2 test.

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