Take away the nice, big sterile operating rooms with a team you know and a stepwise process…step into a tent…100 degree temperature…add a line of desperate, traumatized patients demanding treatment…throw in general chaos. What do you have?
A disaster…a Haiti, a Katrina.
What do you have to work with? Look in the mirror—it’s you, your talent and ingenuity as an orthopedic surgeon and, most of all, your training from the new Disaster Certification Course.
In the face of disasters like Haiti or Katrina, what’s really needed, the experts say, is a cadre of orthopedists specially trained to function appropriately in such extreme situations.
The American Academy of Orthopaedic Surgeons (AAOS), the Orthopaedic Trauma Association (OTA), and the Society of Military Orthopaedic Surgeons (SOMOS) are making this happen.
For those who aspire to join this extraordinary team, there is now an official Disaster Certification Program.
Lynne Dowling, director of the International Department at AAOS, is leading the charge.
This certification program is a direct result of the Haitian earthquake in 2010. Our board recognized that we didn’t have a disaster plan in place that would help members better respond to future events. So, we created a joint project team with the OTA and SOMOS and developed a disaster preparedness plan for AAOS. The plan includes training pathways for members to become certified as ‘AAOS registered disaster responders.’ At this point we have a database with approximately 120 orthopedic surgeons who have been through the program.
“While there were already programs in existence, such as the National Disaster Medical System, and a program through the Department of Health and Human Services, we have streamlined the training pathway. For example, we have made a disaster response course a mandatory training requirement for all three responder types—surge, acute responders, and those in the sustaining phase of a disaster.”
“Our database contains details of which surgeons have received exactly what kind of training. This includes what other certifications they have, such as from the Department of Health and Human Services—or if they are registered to work with Doctors Without Borders, etc. The main thing is that our members get certified in how to work in an austere environment—and that is what our disaster response course does.”
COL Tad Gerlinger, M.D. is the president of the Society of Military Orthopaedic Surgeons. Having gleaned extraordinary lessons from the wartime practice of orthopedics, Dr. Gerlinger and his colleagues were determined that this important knowledge not fade away. “At SOMOS our big ‘push’ has been that these lessons not be lost to time. So much of what we have seen and learned in conflict is useful for disaster situations. This includes crush injuries, explosions, blasts, etc. To preserve this knowledge, SOMOS, OTA and the AAOS came together to create the Disaster Response Course in an effort to prepare orthopedic surgeons to care for the victims of war and disaster in an austere environment.”
“This course is designed for people who are accustomed to the comforts, equipment and facilities of the modern day U.S. hospital. They learn how to function in an environment with limited resources where they may be in some type of danger. We teach them how to conduct surgery safely, how to triage effectively based on resources, and how to treat specific wounds without the customary resources.”
“We prepare orthopedic surgeons for disasters abroad, as well as here in the U.S. At our last meeting we had a physician who was at the Reno airshow disaster. He came to the course because he was inspired to know and do more. My biggest take home message is this: at some point disasters occur in every community…they are everybody’s business.”
COL James Ficke, M.D. is Orthopaedic Surgery Consultant to the U.S. Army Surgeon General. He co-chaired the military focus of expertise—the Extremity War Injuries symposium for 6 years. “I am working with Lieutenant Colonel Warren Kadrmas from the Air Force and Navy Captains Daniel Unger and Eric Hofmeister to facilitate a coordinated military and civilian program. The military is interested in an organized civilian response, and to that end we have been working to see where orthopedic surgeons as a community can contribute. If an orthopedic surgeon responds to a disaster outside the U.S., we want to ensure that there is the appropriate security, as well as platforms where they can work.”
As orthopedic surgeons we have to understand the concepts of damage control orthopedics—external fixation, adequate wound debridement, assessment of soft tissue viability. And because we must be creative when working in austere environments, orthopedists need a good comfort level with their surgical skills. We have to provide safe surgery without the luxury of a C-arm or antibiotics…and we need to know how to do a definitive reconstruction yet leave a limb functional. Think about this: ‘How does an orthopedic surgeon contribute when you can’t take six hours to do a definitive reconstruction because there is a long line of patients waiting?’ That is triage…the kind of thing we teach in this course.
Christopher Born, M.D. is chair of the Disaster Management and Emergency Preparedness committee for the Orthopaedic Trauma Association. He has been a co-director of the disaster response course since the program’s inception. “We have so many well-meaning orthopedic surgeons who are moved to help in the face of a dire situation. The fact is, however, that if you have never worked in a humanitarian/disaster situation then you most likely will have a lot to learn about how to function in these environments. You may be asked to do things you don’t normally do, such as move patients around; you may have to act as a general medical practitioner or assist other surgical subspecialists such as OB/GYN or general surgery.”
“Ethical situations are omnipresent…you can’t just come into a disaster situation and do what you want. We must remember that we are dealing with human beings and even if they are different from you, they should still be afforded the same considerations as the patients you usually treat. An example of a mistake would be doing an operation on a patient that is semi-emergent, and not using an interpreter to tell the patient what you are going to do and what they can expect. Sometimes, you may not have a choice—but you must continue to hold yourself to the highest ethical standards possible.”
“You should not, for example, perform amputations if you have never done that before. And if you are a sports medicine specialist you probably should not do open fracture debridements if you haven’t done them in many years. We also cannot do ill-advised operations, such as internal fixation where sterility is questionable because this will increase the chance of infection. In the disaster response course, we cover what other options surgeons have in situations such as this.”
Surgeons are people of action. But, says Dr. Born, in disasters you just may have to sit back and wait. “It’s imperative that surgeons understand that they are only one component of a larger system that they may not fully appreciate. If you are part of a government team or an NGO that’s coming into a country, you should understand that a lot of organizational work goes on behind the scenes. Cowboys need not apply. Take Haiti, for example. U.S. government teams arrived, but couldn’t be deployed immediately because a supply chain had to be established and permission from the Haitian government to practice medicine needed to be obtained. We also had to find a secure facility in which to work. Setting up a surgical treatment center in an open soccer field where you are surrounded by overwhelmed, hungry people is not a good solution.”
Paul Girard, M.D. has also “been there.” A former Lieutenant Commander in the Navy, Dr. Girard was deployed to Iraq and has served on the USS Comfort. He has led a seminar—Extremity Fractures in an Austere Environment—at the disaster response course on several occasions. “There are two significant clinical lessons that need to be transferred to civilian orthopedic surgeons. First is the management of soft tissue injuries. This is arguably more important than the management of bone injuries. The second thing is conceptual: the management of bone injuries requires a high degree of flexibility—and we surgeons can be a rigid bunch at times. The severity of the wounds and the austerity of the environment require that you account for the personality of the injury in the context of your surroundings and the regional culture when developing treatment plans in this type of setting.”
“We are used to nice, big sterile operating rooms with a team we know and a stepwise process. In an austere environment you have little, if any control over where you work—it could be a tent, or outside—either way it might be 100 degrees. It is imperative to understand that you should not try to utilize the same techniques to manage these patients that you use every day in your hometown. If I normally stabilize a fracture with a rod or plate, in an austere environment I may need to do debridement, cleaning, dressing, and a splint or cast instead of trying to fix it. You have to be prepared to broaden your view to all possible treatment options and think like a resident again.”
Shedding light on how one’s thinking must evolve to participate in disaster response, Dr. Girard says, “An orthopedic surgeon in the audience asked about the use of different types of plates and screws. I let him know that the course isn’t about XYZ implant. He was seeing the trees as opposed to the forest. Let’s say you put in a plate and screws and they remain in the patient for the month you are in the area volunteering. When you leave, another provider from the local area will likely assume care and be responsible for managing that patient’s needs. If the patient develops an infection, you have made the care of that patient that much more challenging if the next surgeon does not have the appropriate instruments to remove the implant. Any care we provide must be reversible by the host nation physicians if things turn sour. The way to think and act when responding to a disaster or humanitarian relief effort is different and not intuitive, and therefore must be passed on and learned.”
Thanks to the dedication of these and other individuals, there is now a way to do just that.
For additional information on the AAOS/OTA/SOMOS disaster course, please visit www.aaos.org.
