Key points
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When possible, disaster-response teams and equipment should be identified and organized before the incident occurs.
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Triage is a difficult but necessary component of disaster-relief and combat casualty management.
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Even in austerity, sound surgical principles and an attempt to achieve a high standard of care should guide the surgeon.
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Caring for severely injured patients, whether they be in the theater of combat or after a natural disaster, can be a rewarding and even life-changing experience for all involved.
Introduction
Oral and maxillofacial surgeons are routinely called on to provide surgical care for severely injured patients. Occasionally, those times may be under extreme circumstances, such as after a natural disaster or in the theater of war. At times like these, even the most highly skilled and experienced surgeon meets significant challenges trying to care for injured patients. This article describes some of the challenges and unique considerations a surgeon and their team encounter in treating these injuries in austere conditions.
Introduction
Oral and maxillofacial surgeons are routinely called on to provide surgical care for severely injured patients. Occasionally, those times may be under extreme circumstances, such as after a natural disaster or in the theater of war. At times like these, even the most highly skilled and experienced surgeon meets significant challenges trying to care for injured patients. This article describes some of the challenges and unique considerations a surgeon and their team encounter in treating these injuries in austere conditions.
Preparation
The process of establishing disaster-response teams and military forward surgical teams extends beyond the scope of this article and likely beyond the responsibility of the oral and maxillofacial surgeon. However, many critical points should still be considered. When possible, personnel and specific roles should be identified, supplies made accessible, and relationships with governmental and nongovernmental organizations established before the incident occurs.
The surgeon treating facial injuries is usually a part of a larger surgical team that includes multiple surgical and medical specialists. Many surgeons of different specialties selflessly volunteered their services after the Haiti earthquake of 2010, but many were frustrated because finding a place to serve was difficult and often not possible. Although surgical specialists were readily available, nurses and support staff were critically short. In wartime or other military operations, the oral and maxillofacial surgeon is typically located at a well-equipped, higher-echelon facility, either afloat or ashore, with well-trained and adequate numbers of support personnel.
Hospital facilities vary with the circumstances of each disaster. Whether the operating room and wards are located in temporary structures or in existing facilities, strict adherence to universal precautions and aseptic technique is essential. Highly communicable diseases such as typhoid and tuberculosis are endemic in many areas of the world, and isolation is difficult at best for those patients who are suspected of having a contagious disease. The World Health Organization recommends that all health care workers be immunized against hepatitis A, hepatitis B, polio, diphtheria, tetanus, and typhoid, at a minimum. Sterilization of surgical instruments is challenging, but many options are available. Instruments must be scrubbed free of organic matter before being sterilized. When possible, autoclaving is the preferred method of sterilizing. If autoclaving is not possible, dry heat or antiseptic (cold sterilization) methods are acceptable. Some recommendations are listed in Box 1 .
- 1.
Autoclaving
- a.
Autoclaving should be the main form of sterilization, when possible.
- b.
Before sterilizing medical items, they must first be disinfected and vigorously cleaned to remove all organic material. Proper disinfection decreases the risk for the person who cleans the instruments.
- c.
Sterilization of all surgical instruments and supplies is crucial in preventing transmission of human immunodeficiency virus (HIV). All viruses, including HIV, are inactivated by steam sterilization (autoclaving) for 20 minutes at 121°C to 132°C or for 30 minutes if the instruments are in wrapped packs.
- d.
Appropriate indicators must be used each time to show that sterilization has been accomplished. At the end of the procedure, the outsides of the packs of instruments should not have wet spots, which may indicate that sterilization has not occurred.
- a.
- 2.
Dry heat
- a.
If items cannot be autoclaved, they can be sterilized by dry heat for 1 to 2 hours at 170°C. Instruments must be clean and free of grease or oil.
- b.
Sterilizing by hot air is a poor alternative to autoclaving, because it is suitable only for metal instruments and a few natural suture materials.
- c.
Boiling instruments is now regarded as an unreliable means of sterilization and is not recommended as a routine in hospital practice.
- a.
- 3.
Antiseptics
- a.
In general, instruments are no longer stored in liquid antiseptic. However, sharp instruments, other delicate equipment, and certain catheters and tubes can be sterilized by exposure to formaldehyde, glutaraldehyde, or chlorhexidine.
- b.
If you are using formaldehyde, carefully clean the equipment and then expose it to vapor from paraformaldehyde tablets in a closed container for 48 hours. Ensure that this process is performed correctly.
- c.
Glutaraldehyde is a disinfectant that is extremely effective against bacteria, fungi, and a wide range of viruses. Always follow the manufacturer’s instructions for use.
- a.
Initial management
When multiple severely injured patients require treatment, it is important to properly sort and organize treatment of the casualties, based not only on the severity and survivability of the injuries but also on the capabilities of the facility. Triage is a stressful but necessary part of disaster-relief management. Meaningful rationing of resources, when absolutely necessary, may reduce overall morbidity and mortality and ensure a sense of fairness to all. Ideally, triage is performed by the most experienced trauma surgeon available. If this practice is not possible, the surgeon charged with the responsibility of triage should be trained and experienced in treating patients who have sustained multisystem injuries, regardless of their specialty.
Initial stabilization is performed by anesthesia, surgery, and emergency department personnel. The American College of Surgeons’ primary and secondary survey as described in Advanced Trauma Life Support for Doctors (ATLS) is an excellent method of initial assessment and resuscitation and is appropriate in both disaster-relief and wartime scenarios. This process is also described in more detail in the article by Ray and Cestero elsewhere in this issue.
Although the treatment of isolated maxillofacial trauma does not usually involve a significant amount of blood loss, transfusion of blood products is often necessary in the severely and multiply injured patient. This is a routine procedure during resuscitations in most hospitals, but it may be a difficult problem in an austere environment. Part of the planning of a disaster relief or military operation must include provisions for transfusions. If the reliable delivery of blood components or apheresis is difficult, using available staff personnel as a walking blood bank may be considered for the delivery of whole blood for resuscitation.
Once the patient has been stabilized, the secondary evaluation and examination can continue. Because advanced radiologic modalities like computed tomography may not be available, a thorough clinical examination is imperative. However, the surgeon may have conventional plain film capabilities, and these may be useful as an adjunct to a clinical examination. Laboratory analysis of blood or other specimens may also not be available, so the team must rely on a thorough history and physical examination in guiding treatment.
Anesthesia considerations
Administering general anesthesia in an austere environment is a challenge and requires innovation. Although fully equipped anesthesia machines and vaporizers may not be available, several options exist for the anesthesia provider. Total intravenous anesthesia (TIVA) has an advantage over conventional inhalational anesthesia in that less equipment is needed and the medications used may be more readily available. TIVA medications (sedative/hypnotics, ketamine, propofol) are generally safe in the stable patient but may be more difficult to use in the unstable multisystem or combat-injured patient. Smaller, portable volatile anesthetic delivery systems are available and may be suited for both disaster-relief and combat environments.
Surgical considerations
In a disaster-relief or combat environment, achieving a desirable result can be difficult and frustrating. In current and recent theaters of war, the injuries sustained were usually caused by improvised explosive devices (IEDs) and high-velocity gunshot wounds. High-velocity gunshot wounds can cause not only significant disruption of soft and hard tissues but also avulsive wounds ( Fig. 1 ). IEDs can cause not only avulsive wounds but also deep and widespread penetration of dirt, rocks, and metal fragments ( Fig. 2 ). Conversely, injuries caused by the earthquake in Haiti in 2010 were associated with high-energy yet low-velocity crush injuries. No matter the situation, the general goal of treatment is to return the patient back to preinjury function and appearance and to resume a normal life.
