Complications in Assessment and Treatment in Disasters and Conflicts

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Introduction

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Wound Infections

Infected wounds can create problems in the first days of an emergency, but can continue to prevent for months. Open injuries with high lev els of contamination (from crush or blast) or at high risk of infection. In situations such as tsunami and flooding, where lacerations come in to contact with untreated water, wound infection is also common. In many settings, access to consumables to maintain adequate wound hygiene and to antibiotics is often restricted, exacerbating risks. Open fractures and prolonged external fixation can all increase the risk of osteomyelitis. Picture 2: Infected wound following a median nerve injury The effects of wound infections can be devastating, creating risks to life and limb. In addition to contaminated wounds, patients with minor burns/wounds and post-operative patients are at risk in many emergency situations. Those who have been displaced from their homes or who are living in insanitary environments with lack of clean water are at higher risk. Patients may have been discharged from overcrowded health facilities where wound care was being undertaken by family members in the absence of adequate community nursing, and may lack the resources or understanding to adhere to high standards of wound, graft or external fixation care.

Missed injuries

Faced with overwhelming numbers of patients, and often with limited access to medical assessment tools including laboratory, imaging and nerve conduction studies, it is to be expected that some conditions will be missed by medical teams when providing lifesaving care. As therapists may be one of the first members of a medical team to review patients following stabilisation or surgery, they may also become aware of missed injuries or other conditions. Commonly, these may include peripheral nerve injuries, non-displaced fractures or mildmoderate brain injuries. Sometimes these may be identified several days (or even weeks) after the injury occurred. Therapists always need to report any unexplained symptoms to a supporting medical team member, and to be aware of signs of deterioration in their patients.

Poorly controlled pain

Pain management is frequently neglected in emergency settings. Rehabilitation professionals may be involved in assessing pain, advising on needs for analgesia, as well as delivering non-pharmacological pain treatments. Some therapy treatments (such as after burn injuries) should be timed to coincide with optimum pain management and dressing changes to optimise pain management. In the first days of a response, or in constrained conflict situations, adaptive approaches to anaesthesia and pain management may be used by the clinical team, as the type and quantity of medications available may be limited. Surgically, nerve blocks and ketamine are commonly used instead of general anaesthesia in conflict and disaster settings. Paracetamol, non-steroidal anti-inflammatories and opioid based analgesics are all on the WHO essential drugs list and so are more likely to be available than other pain medication, as is as amitriptyline, which can be used (if appropriately prescribed) for neuropathic pain. For those responding as part of a classified EMT, your patients should have access to adequate supplies of analgesia. EMT specialist rehabilitation cells are not required to provide medication so should develop links with other local providers. Knowing what drugs are available locally, and if patients need to pay for them, can be helpful. Even if medication is available over the counter in some countries, rehabilitation professionals should not prescribe or advise on medication use beyond their scope of practice. Note that, for extended scope rehabilitation prescribers, you may not be able to prescribe in another country if this is not within the defined scope of your profession in that country. Visual pain charts can be used to assess pain:

Pressure Areas

Many traumatic injuries can increase the risk of pressure ulcers developing, in particular conditions that combine reduced sensation (like spinal or peripheral nerve injuries) with reduced movement (like spinal injuries, brain injuries, or patients on traction). There is evidence of an increase in pressure ulcers in patients, particularly those with spinal cord injuries, in conflicts and disasters. Inadequate pressure relief, staff shortages, lack of education for carers, poor nutrition and hydration, poor bladder and bowel care contributed to preventable pressure ulcers.

Respiratory complications

There are multiple ways in which conflicts and disasters can affect the respiratory system. There are obvious direct causes, such as flooding and tsunami (aspiration pneumonia was a significant issue following the 2004 Indian Ocean tsunami in Aceh), actual chest trauma, inhalation of smoke or volcanic smog. In situations of displacement, overcrowding and damp, insanitary living conditions, acute respiratory infections are also a major cause of morbidity. Patients who are immobile following injury or surgery are also at risk of respiratory complications, as are those who have suffered neurological injury, such as a spinal cord injury or stroke. Disease outbreak like measles can also lead to respiratory complications, such as pneumonias, particularly in children. Finally, recent re-emerging trends in conflicts have included the use of poisonous gases, including chlorine, which can cause respiratory complications

Malnutrition

The drivers of malnutrition in conflicts and disasters will vary depending on the level of food security, feeding practices and pre-emergency health services, as well as how these structures are now affected. Malnutrition (including micronutrient deficiency) in conflicts and disasters can increase morbidity and mortality and impair recovery. Children under five suffering from severe acute malnutrition are at high risk of suffering long-term cognitive and physical impairments. Stimulative therapy and play involving caregivers are recommended once these children are medically stabilised.

Key Points

1. Rehabilitation professionals should be aware of the importance of good nutrition post injury, and should work with the team to ensure patients are appropriately nourished
2. Rehabilitation professionals should be able to identify patients suffering from severe acute malnutrition (SAM), including the use (or referral to the medical team) of Mid Upper Arm Circumference (MUAC) as a reference for this. These patients should be referred to specialist centres for nutrition support
3. Severe micronutrient deficiencies (most commonly iron and Vitamin A) can also impact on recovery. It is good to be aware of common deficiencies in the areas where you are working, and how to identify them
4. Malnutrition also includes obesity. In countries where the population has high obesity levels, there are likely to be more patients affected by non-communicable diseases, such as diabetes and cardiovascular disorders.

Pre-existing Health Conditions

Whilst conflicts and disasters cause injuries, they also disrupt existing systems and health services. This can lead to exacerbation of chronic conditions (such as diabetes, cardiac and respiratory diseases). Trauma patients may have pre-existing health conditions that can exacerbate, or be exacerbated by, their injury. Diabetes is of particular concern for wound healing. People with disability may be disproportionately affected by conflicts and disasters. This is well documented and there is currently more emphasis on the active inclusion of people with disabilities in emergency response. Those with disabilities may be more likely to have been injured or their assistive devices may have been lost; environments may be less accessible and access to regular therapy, medications and care givers may have ceased. Rehabilitation professionals should aim to actively identify these people and work with colleagues, community-based groups or disabled people’s organisations to address their needs.

Key Points

1. Take a full medical history for each patient; consider access to necessary medication or therapy and equipment for chronic conditions
2. Identify and/or collaborate with local healthcare providers to activate a referral pathway for patients requiring follow-up for chronic health conditions
3. Consider the need to replace lost or damaged assistive devices, as well as the need for new devices for people with injuries

Infectious Disease

Infectious disease outbreaks as secondary consequences of emergencies are often exacerbations of endemic diseases caused by the impact of the emergency – whether damage through contamination of water supplies, destruction of health services or displacement and consequential overcrowding. Outbreaks can also occur in conflicts due to the above, as well as longer-term disruption of vaccination and treatment programmes. Common communicable diseases seen in emergencies include diarrhoeal diseases (including cholera), acute respiratory infections, measles, and vector-borne diseases (such as dengue fever and malaria). Pulmonary tuberculosis is also a concern. In some conflict affected areas, diseases that were once close to eradication, such as polio, are now re-emerging. Access to safe drinking water, vaccination programmes and rapid case identification and case management are vital to preventing outbreaks.

Key Points

1. Rehabilitation professionals must be vigilant, firstly in respect to their own personal health and immunisation status, but also in identifying and reporting suspected cases
2. Be aware of the possible need to scale up rehabilitation services to treat survivors of particular outbreaks
3. Be prepared to help spread key public health messages and encourage good practices with your patients KEY pointS

Paediatric Considerations

Though in many countries paediatrics is considered a clinical speciality, in conflicts and disasters all therapists are likely to encounter paediatric patients. Children must be considered as a distinct population. Condition-specific considerations will be mentioned in each chapter, but below are some general considerations: Children are typically injured alongside family members or friends. This has serious psychological and safeguarding implications, which must be addressed concurrently with medical care and rehabilitation. Managing an injured child’s distress should be a priority – don’t force rehabilitation. Children have anatomical and physiological differences to adults. Specifics in relation to injuries will be addressed in the coming chapters. From a respiratory perspective, up to the age of 3, ventilation/perfusion (VQ) matching in children is the opposite to adults: Due to chest wall compliance, the dependent lung is poorly ventilated. To improve VQ matching, position the child with their good lung UP. More information on respiratory therapy in children is contained in the respiratory therapy cheat sheet. Blast injuries in particular often result in poly-trauma, making early rehabilitation more complex. Younger children in particular are more likely to present with associated head and thoracic injuries, while the presence of certain explosive remnants of war (such as cluster munitions) can increase the likelihood of upper limb injuries in children by being mistaken for toys or objects of interest. In some contexts, children with impairments may be socially disadvantaged as a result of their injury, resulting in them not attending school, being kept at home or being perceived as being 62 | EARLY REHABILITATION PATIENT ASSESSMENT AND TREATMENT - THE BASICS CHAPTER 3 | PATIENT ASSESSMENT & TREATMENT - THE BASICS unable to work or marry later in life. Early education with family members and links to peer support can help mitigate this. Injured children may have experienced destruction of their communities, deprivation, forced displacement from their homes, schools and communities and separation from, or loss of, loved ones, including parents. While specific agencies often take overall responsibility for child protection and education, keeping children safe is everybody’s role in humanitarian response. Refer back to Chapter 2 for information about protecting children in your care. 1. Children will require paediatric-sized assistive devices and other equipment. Access to paediatric-specific equipment (such as wheelchairs, crutches, orthotics and prosthetics) is often limited. Where children require assistive devices over extended periods of time, these need to be re-fitted regularly while the child is still growing 2. Carry some child friendly treatment equipment. Carrying some basic toys as part of a treatment bag (even if just bubbles, balloons, and a mobile phone with music or videos) can be really helpful 3. Treatment approaches need to be modified. Consider distraction, play and ageappropriate, activity-based approaches with younger children 4. Where possible, involve family and caregivers in all aspects of the child’s care. This reinforces stability to a child and protects them against further psychological distress. Appreciate who should give consent in a family, according the specific context 5. For continuity and to enhance feelings of protection and stability, try to keep the same staff and translators involved in a child’s care. National staff members may be less intimidating than unfamiliar international staff. 6. Peer support can be invaluable. Children feel more relaxed in the presence of other young people and can offer each other support. Try to group paediatric beds/treatment sessions together and incorporate interactive group games.

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