Biological, Natural, and Human-Induced Disasters: The Role of the Anesthesiologist

Earthquakes

Earthquakes are capable of inducing an incredible amount of damage in a very brief period of time. Resource-limited areas of the world, suffering from poor underlying infrastructure at baseline, are particularly vulnerable to severe damage following an earthquake. The magnitude 7.0 earthquake that struck Haiti on January 12, 2010 was one of the most devastating natural disasters in modern history, and was an example of how badly a nation’s healthcare system can be damaged by this type of event. The death toll in Haiti is difficult to calculate accurately, but nearly all analyses place the number of lives lost at more than 130,000, with 1.5 million people immediately displaced following the earthquake. More than 80% of Haitian schools and more than 50% of Haitian hospitals were destroyed.

Healthcare professionals from around the world recognized that a resource-limited nation such as Haiti would require an incredible amount of assistance to recover from the earthquake. Surgeons, anesthesiologists, and healthcare providers from the United States and other nations traveled to Haiti in order to provide initial trauma care, and subsequently to assist in backfilling the jobs of Haitian healthcare workers who were lost in the earthquake. Médecins Sans Frontières, or Doctors without Borders, stated in 2013 that its response to the Haitian earthquake was the largest relief operation in the history of the organization.

Hundreds of healthcare workers from around the world wanted to participate in the recovery effort from the earthquake, however a major limiting factor was the inability to access the sole airport in Haiti. The United States Air Force assumed leadership of the airport and provided air traffic control until Haitian authorities could recover adequately to resume control. Additional immediate support came with the deployment of one of the two United States Navy Hospital ships, the USNS Comfort . The USNS Comfort and her sister ship, USNS Mercy , are enormous oil tankers that have been converted to hospital ships designed to deliver health care to U.S. military personnel during wartime. In reality, they are now more commonly deployed to provide humanitarian aid to disaster-ravaged areas of the world. In 2010, the USNS Comfort deployed to the coast of Haiti within 72 hours of the earthquake and subsequently embarked upon the largest disaster-relief operation in the history of these floating hospitals. More than 850 patients received care on the ship during the weeks following the earthquake, including 237 children and one premature newborn. The most common condition treated on the ship was musculoskeletal extremity injury, composing about 40% of the overall reasons for admission. The average length of stay was 8 days and surgery was performed 843 times on 454 patients over the course of 5 weeks. Fifty-eight of the operations were amputations. Anesthesiologists from various U.S. hospitals provided care on the USNS Comfort , some as new volunteers and some with prior experience in military and disaster relief ( Figs. 68.1 and 68.2 ).

Provision of medical and surgical care aboard the floating hospital was relatively “normal” when compared with the task of providing care on the island of Haiti itself. Nearly all medical facilities in Port Au Prince were either damaged or destroyed by the earthquake, forcing volunteer healthcare teams to work in makeshift clinics, hospitals, and tent facilities throughout the city. One of the largest such facilities was based out of the United Nations compound at the airport. In the initial days after the earthquake, surgical care was very limited because of a lack of supplemental oxygen, unsterile conditions, and a lack of resources to provide anesthesia. Amputations were performed under local anesthesia until a team of anesthesiologists skilled in single-shot block techniques arrived. Following their arrival, these anesthesiologists were able to facilitate the performance of 1000 operations, including major orthopedic surgery. They were also instrumental in the postoperative care and analgesia of the surgical patients ( Fig. 68.3 ).

Anesthesiologists who travel from resource-rich to resource-limited environments to provide rescue medical care must contend with a lack of familiarity with infectious diseases that have been eradicated from first-world nations. During the Haitian earthquake recovery, this situation confronted anesthesiologists who encountered patients suffering from tetanus. Although not completely eradicated from the United States, few anesthesiologists have any experience caring for patients with tetanus. Caused by the anaerobic bacterium Clostridium tetani , tetanus causes severe neck rigidity, trismus, and chest wall immobility. All of these problems create difficulties for anesthesiologists in terms of airway management and maintenance of ventilation. The Haitian population is at an elevated risk to develop tetanus following contamination of wounds because of relatively lower rates of tetanus vaccination compared with other nations. Anesthesiologists who provided care for surgical patients on the USNS Comfort reported two cases of tetanus that had impact on their anesthetic care. In one case, the patient was noted to have a small mouth opening as a result of trismus. Following induction of general anesthesia with inhaled sevoflurane, the patient’s total body rigidity was markedly improved. Unfortunately, after receiving multiple anesthetics with muscle relaxation, despite receiving appropriate care, the patient had persistent significant muscle weakness, retention of pulmonary secretions, and ultimately pneumonia resulting in his death. In another case, the patient received repeated general anesthetics, consisting of inhaled sevoflurane without neuromuscular blocking drugs. In this case, the patient fully recovered. The anesthesiologists involved in the care of these tetanus victims noted that though the mouth opening is limited, the nasal airway is unaffected by tetanus, so mask ventilation is possible despite the trismus. They also emphasized the importance of conserving medications such as neuromuscular blocking drugs when one is practicing medicine in a severely resource-limited environment so that the drugs are available for the patients most in need. By applying their expertise in pathophysiology and pharmacology, these anesthesiologists were able to safely and effectively deliver surgical anesthesia to high-risk patients without the use of neuromuscular blocking agents by taking advantage of the neuromuscular blocking properties of potent inhaled anesthetic agents.

The Haitian earthquake response highlighted another critical issue associated with all major disasters: the psychological impact on healthcare workers caring for victims. After returning to the United States following humanitarian missions to Haiti, several anesthesiologists wrote thoughtful essays on the care that they had provided. Anesthesiologists who travel to disaster-ravaged areas are exposed to a variety of physical and mental stressors that can have an impact on them for months or years after the event. Prolonged work hours, inadequate rest, exposure to gruesome traumatic injuries, and witnessing the prolonged pain and suffering of children are some examples of what disaster responders endure. Despite these challenges, healthcare providers are expected to provide optimal medical care, while simultaneously providing psychological support to devastated family members. During the busy hours and days of the immediate response to a disaster, healthcare providers stay focused on the call of duty, which allows them to keep personal emotions at bay. As the critical needs resolve, anesthesiologists and other healthcare providers are forced to deal with the physical, mental, and emotional trauma that they themselves have sustained. One might wonder why healthcare providers would leave the safety of their home nation to purposely expose themselves to this kind of potential anguish. Consistent qualities appear to be present among responders to massive natural disasters: they understand that all human beings have dignity, they sympathize with people who are suffering, and they desire to be part of the healing process.

Tornadoes

While tornadoes tend to be shorter in duration than other natural disasters, they are able to create horrendous damage within seconds to minutes. One of the most destructive storms in American history was the tornado rated EF-5 on the Enhanced Fujita scale that ravaged Joplin, Missouri on May 22, 2011. During the ensuing power outage, some hospitals’ backup generators failed, requiring anesthesia care and surgery to be performed by flashlight alone. When hospitals are directly destroyed by natural disasters, as occurred at St. John’s Mercy Medical Center in Joplin, one of the biggest challenges for the community is the need to restore the healthcare infrastructure, including access to the electronic health record. With proper disaster preparedness, including contingencies for complete losses of hospitals and clinics, normal patterns of care can be restored within a reasonable timeframe.

Opportunistic infections are another common downstream effect from all natural disasters, including tornadoes. Following the 2011 tornado in Joplin, a cluster of patients suffering from necrotizing cutaneous mucormycosis was observed and required extensive treatment. Anesthesia providers are critically important during “outbreaks” such as this since emergency surgeries to control rapidly expanding infectious diseases are critical to patient survival ( Figs. 68.4 and 68.5 ).

Tsunami

A tsunami is a very large sea wave that results from a submarine earthquake, volcanic eruption, or other significant geologic movement. On December 26, 2004, a massive earthquake, magnitude 9.1 on the Richter Scale, occurred beneath the Indian Ocean and caused one of the deadliest natural disasters in recorded history. The tsunami that resulted from the earthquake created enormous waves that made their way to the shores of 14 countries, including: Indonesia, Sri Lanka, Malaysia, Bangladesh, India, Thailand, and Myanmar. Tsunamis produce a very high ratio of mortality to injury. These waves result from the influx of water on the shores of victim countries causing the immediate death of many people secondary to drowning or the direct impact of waves or debris. The aftermath of a tsunami tends to have three phases. During phase 1, a high number of people are instantly killed. During phase 2, in the hours and days following the initial impact, relief healthcare workers are able to provide life- and limb-saving care to victims of blunt trauma and water exposure. During phase 3, recovery is impeded by a lack of healthcare personnel and a lack of infrastructure needed to provide longer term posttrauma care.

The 2004 tsunami killed more than 230,000 people, injured tens of thousands, and was estimated to have immediately displaced more than 5 million people. One factor in its extreme lethality was the fact that December is the peak tourist season for many of the beaches of Southeast Asia. As is the case with many tsunamis, there was essentially zero warning that deadly waves were about to make landfall. The Aceh province of the Indonesian island of Sumatra was by far the hardest hit area, with waves reaching greater than 25 m in height and with over 100,000 people killed. People on the beach at the time of the tsunami were killed directly, while people farther inland were killed as a result of drowning or impact with massive floating debris ( Fig. 68.6 ).

While there is essentially no role for relief healthcare workers during phase 1 after a tsunami, healthcare workers from nearby regions can and should respond to care for patients during phase 2. Following the 2004 tsunami, a team of 17 surgeons, 6 anesthesiologists, and other healthcare workers traveled as part of the Thai Red Cross Society for humanitarian mission from Bangkok, Thailand to Phang-Nga, Thailand to provide care. The multidisciplinary team was led by one surgeon and one anesthesiologist. They arrived just 1 day after the tsunami. Over the course of 3 days, the team provided surgical care for 107 patients. The injury profile consisted predominantly of soft-tissue wounds and bone fractures. Halothane was the only inhalational anesthetic available, highlighting the need for anesthesiologists to be nimble in their ability to use older medications during disaster relief.

Most surgical procedures performed in Phang-Nga included general anesthesia following rapid sequence induction. Spinal anesthesia, regional anesthesia, and local anesthesia were also utilized for selected cases. The providers noted an increased incidence of intraoperative oxygen desaturation as compared with findings during other relief operations. The cause for the desaturation is thought to be related to aspiration of seawater and lung contusion secondary to direct impact of waves or debris. In addition to the challenges associated with performing procedures near sites of destruction, providing care can be challenging even if it is being provided remotely relative to the tsunami itself. One common problem is the lack of access to laboratory services. As in post-earthquake anesthetic care, the anesthesiologist may be required to rely on clinical judgment without additional laboratory data to guide decision making in the administration of fluids, electrolytes, antibiotics, and blood products after a tsunami or other natural disaster ( Fig. 68.7 ).

In addition to the regional response, a massive international relief effort was launched in response to the tsunami. In January 2005, Operation Unified Assistance was started as part of the United States response to the catastrophe. Organized by Project HOPE and the U.S. Public Health Service, the USNS Mercy was sent from San Diego, California to the Aceh province in Sumatra, representing the first joint effort of military and civilian relief aboard a U.S. Navy ship. U.S. responders to Indonesia were required to demonstrate up-to-date vaccination records for all typical immunizations, receive vaccines for typhoid and hepatitis A, and take prophylactic medication to protect from malaria. Additionally, negative airflow pods were present on the ship to allow for safe care of patients with active tuberculosis. Prior to arrival, all staff members were briefed on the differences in culture they would encounter, and the possible implications for providing care. More than 90% of Indonesian citizens are Muslim, and Islamic Law plays an important role in the day-to-day decision making, including consent for treatment, end-of-life procedures, and other issues for many of the families impacted by the tsunami.

Another serious outcome after a tsunami is often the loss of life of healthcare workers. An estimated 60% of all healthcare workers in the Aceh province died or were missing following the tsunami. Thus, Operation Unified Assistance was prepared to backfill the roles of lost healthcare workers in addition to providing care directly related to the effects of the tsunami. While the USNS Mercy was designed for enormous overall capacity, for this operation its clinical footprint consisted of staffing for 3 operating rooms and 50 inpatient beds.

Operation Unified Assistance provided surgical care for 154 patients, but only 8.4% of these were in need of surgery as a direct result of the tsunami. Because of the high mortality to injury ratio in a tsunami, the critical need in Aceh was to compensate for the loss of healthcare workers rather than require large numbers of providers to support patients needing surgical procedures. This differentiates the tsunami experience from the Haitian earthquake experience, with its higher relative incidence of survivable injuries.

For those patients requiring surgery, general anesthesia with inhaled agents supplemented by opioids and neuromuscular blocking drugs was the anesthetic technique of choice. Although access to equipment appropriate for regional anesthesia was limited, one of the primary reasons for this approach was related to the significant language barrier between patients and anesthesiologists. In addition, the clinicians felt postanesthesia recovery from general anesthesia would be easier and safer than for neuraxial or regional, considering all of the circumstances. Another commonly needed and often limited resource includes blood and blood products. In this situation, a total of 122 units of packed red blood cells, 13 units of plasma, and 4 units of cryoprecipitate were transfused during the relief operation. While response to a tsunami has some similarities to the response to a large earthquake, the presence of a modern floating hospital allows the anesthesiologist to employ general anesthetic techniques much more readily than in a tent-based operating suite during inland recovery from an earthquake. At the conclusion of Operation Unified Assistance, a portable monitor and anesthetic medications were donated by the team to the local healthcare facility.

Hurricanes

A hurricane is a tropical storm with maximum sustained winds of 74 mph (119 km/h) or higher. Hurricanes have the potential to disrupt the normal function of the healthcare system in a variety of ways. When hurricanes reach landfall, the high wind speeds and excessive rainfall make any outdoor movement unsafe, thus paralyzing emergency medical systems and preventing patients from seeking necessary care. With major hurricanes, extensive flooding is a common complication because of the large volumes of rainfall combined with seawater entrained onto land as part of the storm surge. These storms have fewer immediate fatalities than earthquakes or tsunamis, however the ability of hurricanes to cripple the provision of medical and surgical care has numerous downstream consequences. In this section, Hurricane Katrina will be examined as an example of the destructive forces of hurricanes in general.

In August 2005, Katrina started as a storm over the Bahamas, then gained strength over Florida before reaching the Gulf of Mexico. Over the Gulf of Mexico, Katrina reached Category 5 status with top wind speeds of 175 mph. At the time of landfall, the storm was a category 3 hurricane. It produced 8 to 14 inches of rain over southern Louisiana, Mississippi, and Alabama. At some sites on the Mississippi coast, the storm surge was 25 to 28 feet higher than normal tide level and destroyed the majority of structures in its path. In New Orleans, Louisiana, the storm surge sent water over the levees protecting the city, causing flooding in 80% of the city and the need for widespread evacuation. Hurricane Katrina remains the costliest storm in the history of United States at greater than $100 billion in losses, and it was the deadliest hurricane since 1928 ( Fig. 68.8 ; Table 68.1 ).

The flooding and subsequent displacement of thousands of New Orleans inhabitants following Hurricane Katrina highlight one of the key elements of major natural disasters. In addition to the impact of the hurricane on the healthcare delivery infrastructure, a storm of this magnitude is capable of completely disrupting medical education at the undergraduate and postgraduate levels. New Orleans is home to two major medical schools with accompanying academic and clinical enterprises. Immediately following Hurricane Katrina, the academic and clinical buildings at Tulane University School of Medicine and Louisiana State University (LSU) School of Medicine were both badly damaged by flood waters. Tulane University collaborated with Baylor University College of Medicine in Houston, Texas to use facilities for its medical student programs. LSU utilized facilities on its flagship campus in Baton Rouge, Louisiana for preclinical classes. Housing for students was a challenge, and most Tulane students were hosted by members of the Houston community, while LSU students either found their own housing in Baton Rouge or stayed on a large ferry coordinated by the Federal Emergency Management Agency. Remarkably, both Tulane and LSU were able to resume medical education within 4 weeks of the hurricane.

Relocating preclinical students proved to be easier than identifying suitable clinical education sites for third and fourth-year medical students. Both schools were forced to find new clinical sites within Louisiana and beyond. Compounding the challenge was the closure of the damaged Veterans Affairs Medical Center in New Orleans. This degree of disruption had an impact on the medical school admissions process for both schools, yet both schools were able to enroll incoming classes very much on par with prior years. With regard to the residency match process, Tulane did experience a slight increase in the number of unmatched medical school graduates, likely owing to the reduction in residency spots at Tulane after the hurricane. Despite all of these formidable challenges, both Tulane and LSU were able to keep their entire medical school enterprises alive, though with some impact on faculty needs. Both institutions were able to improve several physical and academic aspects of their campuses in the years following Katrina. In a sense, these two universities have provided other academic centers with a road map for how to continue to thrive following the harrowing experience of an all-encompassing natural disaster. Their perseverance was essential to the future health care of patients in Louisiana and beyond.

While the medical schools’ survival was a triumph, Hurricane Katrina and subsequently Hurricane Rita had a distinctly negative effect on the field of anesthesiology in Louisiana. The two largest teaching hospitals in New Orleans closed after Katrina, and the largest of these—Charity Hospital—never reopened. These closures and other factors led to a decline in the number of anesthesiologists, as documented by a 2006 statewide survey. Statewide residency positions in anesthesiology fell from 24 graduates per year in 2004 to 13 graduates per year in 2007. Like many states, Louisiana is fairly dependent on new anesthesiology graduates remaining in the state to take the place of retiring physicians. Of the respondents, 37% of anesthesiologists reported that they had difficulty filling open positions within their group. In this setting, 92% reported that they had experienced an increase in the number of daily cases, and that obstetric cases for patients with no prenatal care had risen out of proportion to other cases. This phenomenon likely represents a glimpse into the impact of natural disasters on all medical specialties: the same stresses experienced by anesthesiology programs were felt by other residency programs, including the obstetrics and gynecology program. Compared with the complete annihilation of medical infrastructure caused by the earthquake in Haiti, the plight of post-Katrina New Orleans may seem insignificant. Still, the fact that a large city within the wealthiest nation on earth can have its medical infrastructure completely disrupted for months after a storm attests to the impact of large-scale natural disasters.

In September 2017, Hurricane Maria struck Puerto Rico and effectively interrupted the island’s access to clean water, electricity, telecommunications, and transportation. At the time Maria made landfall on Puerto Rico, it had slightly decreased in intensity from a Category 5 to a Category 4 hurricane, yet it damaged or destroyed nearly every structure in its path and the death toll is estimated by different agencies at between 1000 and 2800. Drug and fluid shortages in the continental United States following Hurricane Maria exposed a major vulnerability of the overall healthcare system, and provided anesthesiologists with an opportunity to help lead the way out of a potential nationwide crisis.

Puerto Rico is a massive producer of pharmaceuticals and medical devices. Baxter, a large multinational company had factories in Puerto Rico, producing approximately 50% of all of the 0.9% normal saline bags used each day in U.S. hospitals. The shutdown of these factories, and all other major pharmaceutical factories in Puerto Rico, resulted in an immediate shortage of fluids and medications throughout the United States. The initial response at many mainland hospitals was to identify alternative sources for products in other countries. This approach simply expanded the shortages of fluids and medications internationally.

The experience with shortages of supplies and materials made healthcare leaders recognize the interdependence of all health systems and the importance of conservation of existing supplies and avoidance of waste. In response to the shortages created by the events in Puerto Rico, anesthesiologists at many medical centers were asked to help create strategies to maximize the efficient use of fluids and medications. At the University of Nebraska Medical Center, anesthesiologists worked with other physicians, pharmacists, and leaders in nursing and administration to cocreate robust strategies to avoid critical shortages of necessary fluids and medications. Figs. 68.9 and 68.10 offer a glimpse at some of these strategies. Note that intravenous fluids administered in the operating rooms were required to be on an infusion pump, a major change from the typical “gravity drip” employed by anesthesia providers. The shortages forced healthcare workers across the nation to (1) think more critically about every milliliter of fluid they give to patients, and (2) use different fluids and medications than what they use during times of non-shortage. While the shortages induced by Hurricane Maria were problematic, their net effect has likely been toward positive changes within the U.S. healthcare system. In the aftermath, many have come to realize that our excessive reliance on one U.S. territory for fluids and pharmaceuticals is neither wise nor sustainable.

September 11, 2001 Attacks

On September 11, 2001, an organized team of terrorists commandeered three U.S. airliners with the intention of crashing them into prominent buildings in New York City and Washington, DC. Two of the aircraft were flown directly into the twin towers of the World Trade Center in New York, causing massive fires and eventually causing both of the 110-story buildings to collapse. Nearly 3000 people died as a result of the September 11th attacks, making it the deadliest act of terrorism in recorded history.

An anesthesiologist-intensivist from New York University, Dr. J. David Roccaforte, was on duty at Bellevue Hospital 2.5 miles away from the site of the attack. Dr. Roccaforte’s paper describing the hours and days following the 9/11 attack remains essential reading for healthcare professionals in disaster preparedness. In the paragraphs that follow, the key points from this important paper are summarized.

Hospital phone lines were nonfunctional in the hours following the attack, prompting a recommendation that hospitals be equipped with radio communication equipment and satellite-based communication devices. While cellular communication has clearly improved many-fold between 2001 and 2018, it is difficult to predict the performance of modern networks in a situation where millions of users are simultaneously trying to connect with other users. Based on an assumption that hundreds of victims would be arriving rapidly to the operating rooms and EDs, thousands of dollars worth of fluids, medications, and kits were opened and prepared, much of which went to waste. In retrospect, these resources should have been used only with confirmation of patient need. Considering the number of capable hospitals in New York outside of lower Manhattan, a pre-made plan to triage patients from Bellevue and other nearby hospitals out to other trauma centers would have been beneficial. A field hospital was set up in a warehouse near the World Trade Center, intended to be a site for emergency trauma surgery in the event that hospitals were overwhelmed. Unfortunately, the 100-bed field hospital lacked sufficient resources for the provision of anesthesia, and thus was not entirely usable.

Due to the lack of functional telecommunications, medical students were employed as runners and assigned to attending physicians. All workers were encouraged to wear a label on their shirt with name, specialty, and title, to expedite face-to-face communication. While the 9/11 attack did not induce a major failure of the physical plant at Bellevue, the need for hospital engineers was noted. In the event of a failure of electrical or oxygen supply, head engineers would be needed to restore normal state or provide a contingency plan. A traditional triage system using color-coding was used effectively for incoming patients: green signified non-urgent; yellow for potentially urgent; and red for immediate, life-threatening injuries. Any patient in the yellow category with potential need for airway management or sedation was assigned a senior anesthesiology resident or a critical care fellow. As the initial surge of patients slowed, the team at Bellevue wisely mandated a shift system, sending healthcare workers home to rest and avoid the certain burnout that results from ongoing 24/7 care following a major disaster.