Tsunami Medical Care Resembles U.S. Civil War Era
Jan. 7, 2005 — -- Medical specialists are comparing the emergency medical care problems that have followed the Asian tsunami with another important event in medical history -- the U.S. Civil War.
Like that 19th-century conflict, conditions in field hospitals and local clinics in tsunami-wracked areas are crude at best. Electricity is unreliable, there are no antibiotics, only the simplest medical equipment is available and there are few trained medical specialists.
"These descriptions are reminiscent of wartime mass casualty situations described during times like … the Civil War, or any pre-antibiotic era where amputation was the major treatment of extremity injuries," said Dr. Martin A. Schreiber, director of surgical critical care at Oregon Health & Science University in Portland.
Deciding Who Can Be Saved -- And Who Cannot
Triage is the preferred strategy for dealing with the large numbers of patients in emergency situations. The goal of triage is to ensure the survival of the greatest number of patients by sorting them into groups: those likely to heal on their own, those likely to die regardless of treatment and those expected to improve with medical care, either immediate or postponed.
In triage, only those likely to improve with medical care will receive it. Patients who are expected to die even with medical assistance, and those likely to heal without help, receive little or no treatment.
"In a disaster, there is a major shift in the management of patients, from doing the most for each individual patient to doing the most to get the most survivors," said Dr. Norman McSwain of the Tulane University Department of Surgery in New Orleans.
"Triage is a critical element any time there is a mass casualty situation in the face of limited resources," said Schreiber. "It is very sad."
Saving a Life, Losing a Limb
In a disaster of the magnitude of the Asian tsunami, amputation of limbs may be the only way to save a patient's life.
"Amputation is often the best choice in severely contaminated wounds and can be life saving to avoid overwhelming systemic infection," said Susan Briggs, director of the International Trauma and Disaster Institute at Massachusetts General Hospital in Boston.
"Also, if the extremity is severely crushed, the chance of a functional leg or arm may be minimal," Briggs said.
"If there are no antibiotics, then amputation is better than letting the patient die," said McSwain. "This reverts back to the medicine practiced during the War Between the States. Antibiotics had not been discovered. It was better to take off the infected leg than to let the patient die of generalized sepsis."
Basic Infrastructure Is Lacking
The limits of practicing medicine in the tsunami-affected region are compounded by the lack of infrastructure in the area.
"Unfortunately, this part of the world has chronic problems with their medical systems, which limit the effectiveness of the acute response," said Briggs.
"The biggest problem is the lack of existing infrastructures to be able to transport patients from remote areas to timely medical care and the inability to get supplies … to the affected areas," said Briggs.
The lack of infrastructure in the area goes beyond roads and bridges -- society's support for those who are disabled may also be lacking.
There is a "reluctance of people to have body parts amputated, as the social support system for amputees is non-existent," said Dr. John Gorczyca, chief of the Division of Musculoskeletal Trauma at the University of Rochester Medical Center in Rochester, N.Y.
"This represents a horrible situation, similar to Civil War-era battle treatment," said Gorczyca. "No antibiotics, horrible wounds, severe contamination, lack of surgeons [and] minimal technology."