Injuries and disability: priorities and management for populations affected by the earthquake and tsunami in Asia
Injuries and drowning have accounted for the vast majority of mortality experienced so far in countries affected by the tsunami. Injury related conditions will also account for many of the health care needs among those requiring medical attention in the immediate aftermath of the event. Whether resulting from the earthquake or the tsunami, falling structures, and waters full of swirling debris will have inflicted crush injuries, fractures, and a variety of open and closed wounds.
Appropriate medical and surgical treatment of these injuries is vital to improving survival, minimizing future functional impairment and disability and ensuring as full a return as possible to community life. This briefing paper provides information on what the Department of Injuries and Violence Prevention (VIP) can do to support appropriate care of the injured in the immediate aftermath of the tsunami as well as to prevent future injury.
Care of survivors and identification of persons killed in the event
Care of injured survivors will depend on severity of injury and the extent to which appropriate medical and surgical resources are available. Some of the more important considerations for managing injured survivors include:
- Triage - patients should be categorized by severity of their injuries and treatment prioritized in terms of available resources and chances for survival. The underlying principle of triage is allocation of resources in a manner ensuring the greatest health benefit for the greatest number. More information on triage of injured people may be found online in guidance provided by the Sphere Project.
- Open wounds must be considered as contaminated and should not be closed. Debridement of dead tissue is essential which depending on the size of the wound may necessitate a surgical procedure undertaken in appropriate (e.g. sterile) conditions. Any associated involvement of organs, neurovascular structures, or open bone fractures will also necessitate appropriate surgical care. After debridement and removal of dead tissue and debris wounds should be dressed with sterile dressings and the patient scheduled for delayed primary closure. More information on appropriate surgical and medical care of contaminated open wounds can be found in key references from the International Committee of the Red Cross which, while written for war wounds, provide principles of care entirely relevant for management of open wounds resulting from the tsunami.
- Patients with open wounds should receive tetanus prophylaxis in keeping with the regime presented on pages 4-11 and 4-12 of WHO's Surgical care at the district hospital. Antibiotic prophylaxis or treatment will likely be indicated as well and are discussed on pages 4-10 and 4-11 of this reference.
- Many injuries will be severe enough to lead to long term functional impairment and disability if not managed correctly. Examples include spinal cord injuries, fractures that develop complications such as infection or alignment problems and crush injuries of extremities requiring amputation. Such injuries must be recognized and referred to specialty or tertiary hospitals that can manage such cases and are appropriately equipped with mobility aids, assistive devices and physiotherapy support. This assessment and referral needs to be carried out across the entire spectrum of health facilities handling injured survivors. More information on appropriate management of injuries within health systems can be found in WHO's Guidelines for essential trauma care, and specific guidance on management of spinal cord injuries can be found in WHO's Management of spinal cord injury.
Identification and counting of dead bodies: Identification and counting of dead bodies is important to allow for a better understanding of the magnitude of the disaster and to contribute to the necessary grieving process. This identification can happen through sophisticated methods based on DNA or on much simpler methods based on the identification of e.g. clothing, jewellery.
Prevention of injuries and disability after the event
There are well documented risks for relief workers and affected populations in the aftermath of natural disasters. Buildings may have become structurally unsound, falling debris, or falls onto debris may cause serious injury, and in the present circumstances in at least some settings there has been movement of previously buried anti-personnel landmines. In addition to these external hazards, suicide is a very real risk among distraught survivors. Surveillance systems established to track health indicators of internally displaced and affected populations need to include provisions for systematic collection of injury related data.
Guidance and model questions can be drawn from WHO's Injury surveillance guidelines, community injury survey guidelines, and guidelines for surveillance of landmine injuries. Public authorities need to be proactively involved in ensuring access to potentially hazardous areas is controlled, and provision of safe access to essential needs such as potable water and food needs to be assured.
Longer term needs include provision of appropriate care for and access to community environments for disabled along with appropriate forms of community based rehabilitation and rebuilding the environment for future safety. Valuable lessons can be learnt in the present circumstances about structures, capacities, and safety devices that provided opportunities or increased chances for survival. Physical infrastructure, road design, low cost safety devices and early warning systems combined with disaster planning are all vital components to be incorporated into the planning of the reconstruction phase.
WHO violence and injury expertise and availability for temporary reassignment
- Experience in complex emergencies, displaced populations and camp settings
- Establishment of survey and surveillance systems in limited resource settings
- Epidemiological expertise and rapid health assessment
- Rehabilitation expertise
One senior VIP staff member is available to undertake immediate reassignment for approximately one month. Other staff will be available for short term consultancies.
Violence and injury prevention networks
VIP has a number of collaborating centres and networks of experts with expertise in injury prevention, control and rehabilitation including essential trauma care and management of injured victims and in forensics. Contact details of appropriate individuals could be provided on request.
Department of Injuries and Violence Prevention
World Health Organization
Telephone: +41 22 791 3480
Fax: +41 22 791 4332