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Consensus Statements Regarding the Multidisciplinary Care of Limb Amputation Patients in Disasters or Humanitarian Emergencies: Report of the 2011 Humanitarian Action Summit Surgical Working Group on Amputations Following Disasters or Conflict

Published online by Cambridge University Press:  20 March 2012

Lisa Marie Knowlton*
Affiliation:
Division of General Surgery, University of British Columbia, Vancouver, British Columbia, Canada; Surgical Research Fellow Harvard Humanitarian Initiative, Harvard University, Cambridge, Massachusetts USA
James E Gosney Jr
Affiliation:
Handicap International, Takoma Park, Maryland USA
Smita Chackungal
Affiliation:
Division of General Surgery, University of Western Ontario, London, Ontario, Canada; Surgical Research Fellow, Harvard Humanitarian Initiative, Harvard University, Cambridge, Massachusetts USA
Eric Altschuler
Affiliation:
Department of Physical Medicine and Rehabilitation, New Jersey Medical School, Newark, New Jersey USA
Lynn Black
Affiliation:
Department of Medicine, Massachusetts General Hospital, Boston Massachusetts USA
Frederick M Burkle Jr
Affiliation:
Senior Fellow and Scientist, Harvard Humanitarian Initiative, Harvard University, Boston, Massachusetts USA
Kathleen Casey
Affiliation:
Director, Operation Giving Back, American College of Surgeons, Chicago, Illinois USA
David Crandell
Affiliation:
Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts USA
Didier Demey
Affiliation:
Physical Therapist, Technical Advisor for Emergency and Rehabilitation, Handicap International, Brussels, Belgium
Lillian Di Giacomo
Affiliation:
Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland USA; Division of General Surgery, University of California at Davis Medical Center, Sacramento, California USA
Lena Dohlman
Affiliation:
Assistant Professor, Harvard Medical School, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts USA
Joshua Goldstein
Affiliation:
Principal Director for Economic Citizenship & Disability Inclusion, Center for Financial Inclusion at ACCION International; Lecturer, Boston University, Boston, Massachusetts USA
Richard Gosselin
Affiliation:
Institute for Global Orthopedics and Traumatology, University of California at San Francisco, San Francisco, California USA
Keita Ikeda
Affiliation:
Post Doctorate Fellow, Duke University Medical Center, Department of Anesthesia, Raleigh, North Carolina USA
Andree Le Roy
Affiliation:
Physiatrist, Spaulding Rehabilitation Hospital, Cambridge, Massachusetts, USA; Instructor, Harvard Medical School, Boston Massachusetts, USA
Allison Linden
Affiliation:
Harvard School of Public Health, Boston, Massachusetts USA; Georgetown University Hospital, Washington, District of Columbia USA
Catherine M Mullaly
Affiliation:
Department of Anesthesia, Massachusetts General Hospital, Boston, Massachusetts USA; Instructor, Harvard Medical School, Boston Massachusetts USA
Jason Nickerson
Affiliation:
Centre for Global Health, Institute of Population Health, University of Ottawa, Ottawa, Ontario, Canada
Colleen O'Connell
Affiliation:
Research Chief, Stan Cassidy Centre for Rehabilitation, Fredericton, New Brunswick, Canada
Anthony D Redmond
Affiliation:
Humanitarian and Conflict Response Institute, University of Manchester, Manchester, UK
Adam Richards
Affiliation:
American Heart Association-Pharmaceutical Outcomes Research Center, UCLA Department of Neurology, Los Angeles, California USA; Global Health Access Program, Berkeley, California USA
Robert Rufsvold
Affiliation:
Medical Director, International Medical Corps Emergency Response, Libya
Anna LR Santos
Affiliation:
Delft University of Technology, Delft, Netherlands
Terri Skelton
Affiliation:
Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
Kelly McQueen
Affiliation:
Fellow, Harvard Humanitarian Initiative, Harvard University, Cambridge, Massachusetts USA; Valley Anesthesiology Consultants, Phoenix, Arizona USA
*
Corresponding Author: Lisa Marie Knowlton, MD, MPH Division of General Surgery, University of British Columbia, 910 West 10th Avenue, Room 3100, Vancouver, British Columbia Canada V5Z 4E3, E-mail: drlisaknowlton@gmail.com

Abstract

Limb amputations are frequently performed as a result of trauma inflicted during conflict or disasters. As demonstrated during the 2010 earthquake in Haiti, coordinating care of these patients in austere settings is complex. During the 2011 Humanitarian Action Summit, consensus statements were developed for international organizations providing care to limb amputation patients during disasters or humanitarian emergencies. Expanded planning is needed for a multidisciplinary surgical care team, inclusive of surgeons, anesthesiologists, rehabilitation specialists and mental health professionals. Surgical providers should approach amputation using an operative technique that optimizes limb length and prosthetic fitting. Appropriate anesthesia care involves both peri-operative and long-term pain control. Rehabilitation specialists must be involved early in treatment, ideally before amputation, and should educate the surgical team in prosthetic considerations. Mental health specialists must be included to help the patient with community reintegration. A key step in developing local health systemsis the establishment of surgical outcomes monitoring. Such monitoring can optimizepatient follow-up and foster professional accountability for the treatment of amputation patients in disaster settings and humanitarian emergencies.

Type
Original Research
Copyright
Copyright Knowlton © World Association for Disaster and Emergency Medicine 2012

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References

1.World Health Organization. World Report on Disability. 2011. Available at: http://www.who.int/disabilities/world_report/2011/en/index.html. Accessed on 24 June 2011.Google Scholar
2.World Health Organization/Pan American Health Organization: Guidelines on International Foreign Medical Teams. Proceedings of the WHO/PAHO technical consultation on International Foreign Medical Teams (FMTs) Post Sudden Onset Disasters (SODs). Havana, Cuba. 7-9 December 2010.Google Scholar
3.Working Groups Background Paper: Accountability, Quality Control and Reporting. Proceedings of the WHO/PAHO Technical Consultation on International Foreign Medical Teams (FMTs) Post Sudden Onset Disasters (SODs). Havana, Cuba. December 7-9, 2010.Google Scholar
4.Working Groups Background Paper: Registration, Certification and Coordination. Proceedings of the WHO/PAHO Technical Consultation on International Foreign Medical Teams (FMTs) Post Sudden Onset Disasters (SODs). Havana, Cuba. December 7-9, 2010.Google Scholar
5.Landry, MD, O'Connell, C, Tardif, G, Burns, A. Post-earthquake Haiti: the critical role for rehabilitation services following a humanitarian crisis. Disability and Rehabilitation, 2010; 32(19): 16161618.Google Scholar
6.Gosney, JE Jr. Physical Medicine and Rehabilitation: Critical Role in Disaster Response. Disaster Medicine and Public Health Preparedness, 2010;4(2):110112.Google Scholar
7.Merin, O, Nachman, A, Levy, G, Schwaber, MJ, Kreiss, Y. The Israeli Field Hospital in Haiti – Ethical Dilemmas in Early Disaster Response. N Engl J Med, 2010;362(38): 13.Google Scholar
8.Keane, M, Pack, ME, Greenough, PG, Buckle, FM Jr: The professionalization of humanitarian health assistance: report of a survey on what humanitarian health workers tell us. PrehospDisast Med. 2009;24(Suppl. 2):s2046.Google Scholar
9.Bradt, DA, Drummond, CM: Professionalization of Disaster Medicine – an appraisal of criterion-referenced qualifications. PrehospDisast Med. 2007;22(5):360–8.Google Scholar
10.McQueen, K, Parmar, P, Keane, M, Broaddus, S et al. : Burden of Surgical Disease: Strategies to manage an existing public health emergency. PrehospDisast Med. 2009;24(Suppl. 2):s22831.Google Scholar
11.World Health Organization: WHO Best Practice Guidelines on Emergency Surgical Care in Disaster Settings. 2005. Available at www.who.int/surgery/publications/disastermanagguide.pdf. Accessed 14 March 2011.Google Scholar
12.World Health Organization: WHO Surgical Care at the District Hospital. 2003. Available at http://www.who.int/surgery/publications/en/SCDH.pdf. Accessed 02 March 2011.Google Scholar
13.Gianou, C, Balden, M, (eds). War Surgery Vol 1. Geneva: International Committee of the Red Cross, 2009.Google Scholar
14.Betrancourt, B, Dufour, D, Jensen, SK, et al. . International Committee of the Red Cross. Surgery For Victims of War. Geneva: 1998. Available at http://www.emro.who.int/lebanon/crisis/War%20Surgery%20ICRC.pdf Access 01 March 2011.Google Scholar
15.US Army Borden Institute. Care of the Combat Amputee. 2009. Available at http://www.bordeninstitute.army.mil/published_volumes/amputee/amputee.html. Accessed 01 March 2011.Google Scholar
16.International Campaign to Ban Landmines Working Group on Victim Assistance. Guidelines for the Care and Rehabilitation of Survivors. 1999. Available at http://www.essex.ac.uk/armedcon/story_id/Guidelines%20for%20the%20care%20and%20Rehabilitation%20of%20Survivors.pdf. Accessed on 11 March 2011.Google Scholar
17.Amputation Coalition of America. Experts Reach Consensus on Amputation Techniques for War Injuries. 2008. Available at http://www.amputee-coalition.org/inmotion/may_jun_03/military.html. Accessed on 07 March 2011.Google Scholar
18.Amputation Surgery Education Center. General Principles of Amputation Surgery. Available at http://www.ampsurg.org/html/fundopen.html. Accessed on 12 March 2011.Google Scholar
19.Handicap International. The rehabilitation of amputees victims of landmines. 2006. Available at http://www.apminebanconvention.org/fileadmin/pdf/mbc/IWP/SC_may06/speeches_va/HI_Promotion_first_aid_9May06.pdf. Accessed on 28 Feb 2011.Google Scholar
20.United States Department of Veteran Affairs/Department of Defense. Guidelines: Rehabilitation of Lower Limb Amputation. 2010. Available at http://www.healthquality.va.gov/Lower_Limb_Amputation.asp. Accessed on 19 Feb 2011.Google Scholar
21.American Academy of Orthopedic Surgeons. Clinical Practice Guidelines. Available at http://www.aaos.org/research/guidelines/guide.asp. Accessed on 07 March 2011.Google Scholar
22.Sphere Project: Sphere Handbook: Humanitarian Charter and Minimum Standards in Disaster Response. 2011. Available at http://www.sphereproject.org/content/view/682/32/lang,english/. Accessed 14 April 2011.Google Scholar
23.International Association for the Study of Pain. Pain Clinical Updates: Pain and Rehabilitation from Landmine Injury. 1998; 6(2). Available at http://www.iasp-pain.org/AM/AMTemplate.cfm?Section=Home&TEMPLATE=/CM/ContentDisplay.cfm&CONTENTID=7590&SECTION=Home. Accessed 27 Feb 2011.Google Scholar
24.Poçan, et al. . Crush syndrome and acute renal failure in the Marmara earthquake. Mil Med (2002) vol. 167 (6) pp. 516–8.Google Scholar
25.Oda, et al. . Crush syndrome sustained in the 1995 Kobe, Japan, earthquake; treatment and outcome. Ann Emerg Med (1997) vol. 30 (4) pp. 507–12.CrossRefGoogle ScholarPubMed
26.Missair, A, Gebhard, R, Pierre, E, Cooper, L, Lubarsky, D, Frohock, J, Pretto, EA Jr. Surgery under Extreme Conditions in the Aftermath of the 2010 Haiti Earthquake: The Importance of Regional Anesthesia. Prehosp Disaster Med. 2010 Nov-Dec;25(6):487–93.Google Scholar
27.Buckenmaier, et al. . Continuous peripheral nerve block for battlefield anesthesia and evacuation. RegAnesth Pain Med (2005) vol. 30 (2) pp. 202–5.Google Scholar
28.Neal, et al. . ASRA practice advisory on local anesthetic systemic toxicity. RegAnesth Pain Med (2010) vol. 35 (2) pp. 152–61.Google Scholar
29.Size, M, Soyannwo, OA, DM, Justins: Pain Management in Developing Countries. Anesthesia. 2007;63(Suppl 1):3843.Google Scholar
30.Lohman, D, Schleifer, R, Amon, JJ. Access to Pain Treatment as a Human Right. BMC Med. 2010;8:8.Google Scholar
31.Brennen, F, Carr, D.B, Cousins, M: Pain Management: A Fundamental Human Right. Anesthesia and Analgesia. 2007;105(1):205221.Google Scholar
32.Craven, R: Ketamine. Anesthesia. 2007;62(Suppl 1):4853.Google Scholar
33.Bonanno, . Ketamine in war/tropical surgery (a final tribute to the racemic mixture). Injury (2002) vol. 33 (4) pp. 323–7.Google Scholar
34.Schnittger, T: Regional anesthesia in Developing Countries. Anesthesia. 2007; 62(Suppl. 1):4247.Google Scholar
35.Hayes, et al. . Perioperative intravenous ketamine infusion for the prevention of persistent post-amputation pain: a randomized, controlled trial. Anaesth Intensive Care (2004) vol. 32 (3) pp. 330–8.Google Scholar
36.World Health Organization: WHO Model List, 16th ed (updated). 2010. Available at www.who.int/medicines/publications/essesntialmedicines/en/index.html. Accessed 14 Mar 2011.Google Scholar
37.American Society of Anesthesiologists Task Force on Acute Pain Management. Practice guidelines for acute pain management in the peri-operative setting: an updated report by the American Society of Anesthesiologists Task Force on Acute Pain Management. Anesthesiology. 2004;100:15731581.Google Scholar
38.Bone, et al. . Gabapentin in postamputation phantom limb pain: a randomized, double-blind, placebo-controlled, cross-over study. RegAnesth Pain Med (2002) vol. 27 (5) pp. 481–6.Google Scholar
39.Bloomquist, . Amputation and phantom limb pain: a pain-prevention model. AANA J (2001) vol. 69 (3) pp. 211–7.Google ScholarPubMed
40.Barbosa, et al. . Neuraxialanaesthesia for lower-limb revascularization. Cochrane Database Syst Rev (2010) (1) pp. CD007083.Google Scholar
41.Martin, et al. . Severe phantom leg pain in an amputee after lumbar plexus block. RegAnesth Pain Med (2003) vol. 28 (5) pp. 475–8.Google Scholar
42.Scheman, et al. . Flashback and nightmares after surgery under neuraxial anesthesia: a report of two cases. Arch Phys Med Rehabil (1998) vol. 79 (5) pp. 579–81.Google Scholar
43.Buckenmaier, C. Defense and Veterans Pain Management Initiative. The Military Advanced Regional Anesthesia and Analgesia Handbook. 2008. Available at http://www.arapmi.org/maraa-book-project.html. Accessed 18 April 2011.Google Scholar
44.Ramachandran, VS, Rogers-Ramachandran, D, Cobb, S. Touching the phantom limb. Nature. 1995 Oct 12;377(6549):489–90.Google Scholar
45.Chan, BL, Witt, R, Charrow, AP, Magee, A, Howard, R, Pasquina, PF, Heilman, KM, Tsao, JW. Mirror therapy for phantom limb pain. New Engl J Med. 2007 Nov 22;357(21):2206–7.CrossRefGoogle ScholarPubMed
46.Ramachandran, VS, Altschuler, EL. The use of visual feedback, in particular mirror visual feedback, in restoring brain function. Brain. 2009 Jul;132(Pt 7):1693–710.Google Scholar
47.O'Connell, C, Shivji, A, Calvot, T. Handicap International Report: Earthquake of 12th January, 2010 – Haiti: Preliminary Findings About Persons With Injuries. 29 Jan 2010. Available at http://www.operationgivingback.facs.org/stuff/contentmgr/files/f3c4e87c7ceca489d3197cab5d6de592/miscdocs/pinternational_preliminaryfindingsaboutinjuries_1feb2010.pdf/. Accessed on 18 Feb 2011.Google Scholar
48.Gawande, A. Casualties of War – Military Care for the Wounded from Iraq and Afghanistan. N Engl J Med. 2004;351:24712475.CrossRefGoogle ScholarPubMed
49.Clasper, JC. Regional anesthesia, ballistic limb trauma and acute compartment syndrome. JR Army Med Corps. 2010 Jun;156(2):77–8.Google Scholar
50.Mannion, SJ, Chaloner, E. Principles of war surgery. Br Med J 2005; 330:14981500.Google Scholar
51.Cummings, D. Prosthetics in the developing world: a review of the literature. ProsthetOrthot Int. 1996;20:5160.Google Scholar
52.Lisa, I, IezzoniMD, MSc MD, MSc, and Laurence, J. Ronan, MD. Disability Legacy of the Haitian Earthquake. Ann Intern Med. 2010;152:812814.Google Scholar
53.Eitel, S. Haiti Mission Report Feb-Mar 2010. USAID. Available at oneresponse.info/.../Haiti/.../Eitel%20Haiti%20Feb-Mar%202010%20Report%20-final%20draft.doc. Accessed 25 April 2011.Google Scholar
54.ISPO consensus conference on appropriate orthopaedic technology for low-income countries: conclusions and recommendations. ISPO Technologies 2001. Available at http://www.ncbi.nlm.nih.gov/pubmed/11860089. Accessed 25 April 2011.Google Scholar
55.USIS Prosthetics and Orthotics Program Guide. Implementing P&O Services in Low-Income Settings. USISPO 2010. Available at http://www.usispo.org/assets/pdf/Programme_Guide_Final_Version.pdf. Accessed 25 April 2011.Google Scholar
56.Appropriate Prosthetic and Orthotic Technologies in Low-Income Countries 2000-2010. USAID/ISPO 2010. Available at http://www.healinghandsforhaiti.org/LinkClick.aspx?fileticket=g%2FkPUGJbFT4%3D&tabid=73&language=en-US. Accessed 25 April 2011.Google Scholar
57.US International Society for Prosthetics and Orthotics. USISPO Develops Code of Conduct for Humanitarian Assistance. Available at http://www.usispo.org/news-code_conduct.asp. Accessed 26 April 2011.Google Scholar
58.Jacobson, E.An Introduction to Haitian Culture for Rehabilitation Service Providers. CIRRIE Monograph Series 2003 [Online]. New York: Buffalo University Press. Available at http://cirrie.buffalo.edu/monographs/haiti.pdf. Accessed 24 April 2011.Google Scholar
59.Ingstad, B. and Reynolds White, S. (eds.). Disability and culture. 1995. Berkley: University of California Press.Google Scholar
60.World Health Organization. Violence and Injury Prevention and Disability: Community-Based Rehabilitation Guidelines. 2011. Available at http://www.who.int/disabilities/cbr/guidelines/en/index.html. Accessed 23 April 2011.Google Scholar
61.International Committee of the Red Cross. Haiti: thousands of disabled Haitians to benefit from rebuilt clinic. Available at http://www.icrc.org/eng/resources/documents/news-release/2010/haiti-news-2010-11-15.htm. Accessed 15 March 2011.Google Scholar
62.Potter, BK, Scoville, CR. Amputation is not isolated: an overview of the U.S. Army amputee patient care program and associated amputee injuries. J Am AcadOrthop Surg. 2006;14:S188S190.Google Scholar
63.Charlton, E: The management of post-operative pain. Update in Anaesthesia. 1997;7(23):17.Google Scholar
64.Chu, K. Improving Effective Surgical Delivery in Humanitarian Disasters: Lessons from Haiti. PLOS Medicine. 2011;8(4):14.Google Scholar