Thursday, January 14, 2010

Medical Consequences of an Earthquake in Haiti. Trauma, Crush Injuries, Infectious Disease and Stress Disorders: A Population-Based Care Perspective

Count on the science of medical epidemiology to leave no manmade or natural disaster go unexamined. Examples include the medicalization of nuclear war, inquiries into the risks associated with depletion of the ozone layer and more recent alarming reports on 9-11 and global warming. Given the epic tragedy unfolding in Haiti, the Disease Management Care Blog wondered if a) earthquakes were also a topic in the medical literature and, if so, b) what it could tell us about them from a population-based health perspective.

The answers are yes and lots.

It looks like there are four stages to a disaster like this.

1. In the initial hours, the risk of traumatic death is not only dependent on proximity to the epicenter, but being in taller buildings and on the upper floor. In fact, it's the large structures in an affected area that are the greatest threat. Immediate causes of injury include not only building collapse but falling debris, falls, motor vehicle accidents and burns. Low socioeconomic status, severe mental illness, moderate (not persons with 'severe', because they are being cared for) physical disability or being just having been discharged from a hospital are associated with a higher likelihood of death.

For those victims who make it out, the majority won't necessarily need to go to a hospital - assuming those facilities are still functioning. Instead, survivors are typically treated outside in makeshift stations or individually on the street. Those individuals with life-threatening chest or head trauma often don't get to the hospital on time; if they do make it, it's more likely that that trauma was minor. Instead, what fills the hospitals' emergency rooms, operating rooms and inpatient beds in the first wave are persons with severe limb fractures.

2. What follows next are the crush injury victims who are pulled out of the rubble. Survival with chest or abdominal trauma is relatively uncommon, so once again, it'll be these victims' limbs that require treatment. Laying in one position and being unable to move for hours or days with or without crush injuries can also lead to considerable swelling or the arm or leg, which often necessitates 'fasciotomies,' i.e., surgically opening the skin (explanation and picture) to accomodate the swelling. This allows this edema to run its course without squeezing off the local blood supply. These injuries can also lead to the release of high amounts of muscle protein into the blood stream (called 'rhabdomyolysis'), which is toxic to the kidneys. Avoiding kidney shut-down (failure) involves complicated medical treatment which is often out of the reach of first responders. If the failure turns out to be permanent as the hours to days unfold, the lack of access to dialysis is a death sentence for those victims who are otherwise joyously rescued alive from the rubble.

3) In the days and weeks that follow, there is the specter of outbreaks of infectious diseases. Thanks to overcrowding as persons seek shelter combined with the breakdown of fresh water transport and sanitation, insect borne diseases, contaminated water, measles, respiratory illnesses and meningitis can emerge as a huge threat to the survivors. Vaccinating against measles is important and chlorine, not boiling water, may be a better first line of defense for potable water. This is where the work of establishing camps with adequate shelter, clean water and sanitation, food and nutrition are critical over the longer haul. Haiti's special burden of HIV and tuberculosis (TB) should also warrant special attention to minimize spread to the uninfected. Last but not least, this is probably when the arrival of increased numbers of relief workers results in some of that group also being exposed to injury.

4. Finally, there's the high incidence of post traumatic stress and the increased risk of suicide. The psychological burden can last for years and cannot be underestimated.

Despite the initially insurmountable logistics, this can be the Obama Administration's finest hour. Based on what the DMCB is reading, their planning should emphasize finding, assembling and equipping local 'first responders' who can supply first aid in the streets. In addition, medical experts with knowledge of treating trauma and, in particular, orthopedic injuries are critically needed right now. They should be followed by other surgeons as well as health providers that can manage the rhabdomyolysis and, if possible, provide emergency dialysis. Planning for camps should be starting by now to head off the risk of overcrowding, poor sanitation and communicable disease; vaccines should be on the way and special services for HIV and TB need to be arranged, along with mental health services.

The DMCB hopes and prays for the brave people of Haiti.

The Red Cross is accepting donations, which can be accessed here.


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