On the morning of 25 April 2015, Nepal was struck by a 7.8 magnitude earthquake. The death toll exceeded 9000, and over 23 000 were injured.1 An Israeli disaster response force, comprising search and rescue abilities and a field hospital, was assembled in the first hours following reports of the earthquake. The field hospital was rapidly deployed by the Israeli Defence Forces (IDF) Home Front command and Medical Corps. It opened its gates 82 h after the earthquake and operated for 11 days, treating over 1600 patients and performing over 100 surgical procedures. The IDF Field Hospital facilities, staff and equipment were based on the experience from previous worldwide missions,2 and included an emergency department, 40 adult admission beds, five paediatric beds, a nine-bed ICU which also functioned as a post-anaesthesia care unit, two operating rooms, radiology and laboratory services and medical informatics. The hospital personnel composed of 126 people, including 42 physicians. The latter included three anaesthesiologists, seven orthopaedic surgeons, five general surgeons, a plastic surgeon, an ophthalmologist, an ENT surgeon, three intensive care specialists, five internal medicine specialists, four paediatricians and two obstetricians. In addition, there was a full complement of military paramedics, nurses and support personnel. The majority of the surgical procedures were orthopaedic and plastic surgery and regional nerve blocks were used to facilitate most of these surgical interventions.
During the 11 days of the IDF Field Hospital operation, 88 operations were performed and these included 114 different surgical procedures, ranging from wound debridement, amputation and external fixation, through laparotomy and caesarean section to definitive maxillofacial surgery. When applicable, nerve blocks were used for peripheral surgery: either a femoral or saphenous block, a high or low sciatic block or a combination was used for foot, leg and knee operations; an interscalene or a supraclavicular block was used for hand, arm and shoulder operations. Intravenous access was established before block placement. Standard monitoring for all patients during surgery included a three-lead electrocardiogram, noninvasive blood pressure and blood oxygen saturation. A major limitation of regional anaesthesia in such situations is the difficulty in communicating with the patients, as most of them do not speak English. Fortunately, we were able to use local volunteers for translation services.
When possible, nerve blocks were performed in the ward or preoperative holding area before the patient entered the operating room, enabling an almost immediate start to surgery and better use of resources. All nerve blocks were performed using aseptic techniques with ultrasound guidance provided from a portable ultrasound machine and a high-frequency linear probe (180 Plus; SonoSite, Bothell, Washington, USA). Owing to the unavailability of short bevelled atraumatic needles, 21G 40-mm needles (OMG, Wenzhou, China) were used. Owing to the fact that most of our patients were thin, the majority of the nerve blocks could be performed using these short needles. Bupivacaine 0.25 to 0.5% (AstraZeneca, London, UK) was used in doses between 2 and 3 mg kg−1. Operations were performed on either awake patients or patients under mild sedation, using intravenous ketamine (1 to 2 mg kg−1) and intravenous midazolam (20 to 100 μg kg−1).
Most (96%, 81 of 84) orthopaedic and plastic surgery procedures on nonventilated patients were conducted under regional nerve blocks, with the remaining three (4%) preformed under general anaesthesia (2) and spinal anaesthesia (1). All nerve blocks provided adequate analgesia, and no immediate complications were documented. In the patients receiving nerve blocks, postoperative pain was minimal in the first 24 h following the operation and most required no supplemental analgesia. Simple analgesics (oral paracetamol 20 mg kg−1 or metimazole 20 mg kg−1) were needed in some of the patients, but opioids were rarely needed.
Regional anaesthesia has been widely used with good results in austere environments and resource-poor conditions,3 in both civilian and military settings,1 and has been reported to be a valuable tool following a number of natural disasters.2,4,5 The choice of regional anaesthesia was dictated by four major factors: first, the relative simplicity of the techniques make them safer in the absence of advanced monitoring and with limited patient history and laboratory facilities; second, recovery from general anaesthesia would require the use of an ICU/post-anaesthesia care unit bed, a scarce resource in the disaster setting which may limit operating room turnover or access to ICU beds by other patients; third, avoiding general anaesthesia minimises the need for supplemental oxygen, another scarce resource in the setting of a field hospital; and fourth, the limited medical and nursing staff together with communication difficulties with patients during the postoperative period requires an anaesthetic technique that minimises postoperative pain and opioid requirements. In addition, in the Nepalese culture in which self-control is important, and the concepts of both physiological and psychological trauma are different, avoiding general anaesthesia may better serve the overall process of healing.6 Finally, should aftershocks require emergency evacuation during surgery, the patient is more easily moved.
The use of ultrasound-guided nerve blocks for limb surgery in earthquake survivors not only saves turnover time and recovery from anaesthesia3 while providing safe surgical conditions and good pain relief,3,7 but also simplifies inter and intra-hospital patient transfer.8 Planners of future disaster relief forces need to consider assigning anaesthesiologists with substantial regional anaesthesia skills, and confirm the availability of adequate, portable ultrasound equipment, specific short bevel block needles of different lengths and appropriate local anaesthetics in different concentrations. Regional anaesthesia is feasible and safe, and its use can conserve resources in disaster relief settings.
Acknowledgements related to this article
Assistance with Editorial: the authors would like to thank Israel Defence Medical Corps Information Technologies Division, who made data retrieval and analysis possible.
Financial support and sponsorship: none.
Conflicts of interest: none.
Comment from the Editor: this editorial was checked and accepted by the editors but was not sent for external peer review.
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