Paraplegia 31 (1993) 168-171 © 1993 International Medical Society of Paraplegia

The development of a spinal injuries unit in Armenia

DC Burke FACRM FRACP FRACS,l D Brown FRACP FACRM,2 V Hill FACRM,3 K Balian MD,-t A Araratian MD,4 C Vartanian MD-t

1 Austin Hospital Royal Talbot Rehabilitation Centre, Melbourne, Victoria, Australia; l 3 Spinal Injuries Unit, Austin Hospital, Melbourne, Victoria, Australia; Spinal Injuries Unit, Princess Alexandra Hospital, Wooloongabba, Brisbane, Queensland, Australia; -' Armenian Spinal Unit, Yerevan, Armenia.

A severe earthquake in December 1988 in Armenia, resulted in a large number of spinal cord injuries. A rehabilitation facility was urgently established in Yerevan by the Red Cross with volunteers from various countries outside the then Soviet Union. A programme of training of Armenian doctors, nurses and therapists was established, and a new purpose built spinal unit planned. The new unit was opened in August 1992 and should serve as a model for similar units throughout the Commonwealth of Independent States.

Keywords: earthquake; spinal cord injuries; Armenian spinal unit.

Introduction tation team. Two of the authors were approached to be team leader and to help A severe earthquake on 7 December 1988 in establish the unit. One of the doctors (1) Armenia killed at least 25,000 people, in­ arrived in Yerevan by the end of February jured more than 150,000, and left 500,000 1989 to lead the team for the first 3 months, people homeless. Amongst those injured followed by the second doctor (2) for 3 were a large number with spinal cord months. The third author (3) led the team injuries. It became apparent that the spe­ for 3 months until the end of 1989, when it cialised facilities required to deal with the was decided to continue the work beyond spinal cord injured were grossly inadequate. the original planned 6 months. The initial The Armenian government and the Soviet team of nurses and physiotherapists were Red Cross appealed to the League of Red recruited from Ireland, France, Germany, Cross and Red Crescent Societies for assist­ Japan, Canada and United States. An airlift ance and it was decided to set up a spinal of equipment was arranged from Geneva. cord unit in Yerevan, the Armenian capital. The team commenced working in the This paper describes the first 12 months of Scientific Research Institute of Physio­ establishing a treatment programme and therapy in the first week of March when the initiating a training programme for Armen­ team had been assembled and some equip­ ian staff. It will briefly describe the status of ment had arrived. In June, two occupational the new unit today, but a further paper is therapists and an orthotist joined the team. foreshadowed which will describe in detail The composition of the team changed over the training programme and opening of the the reported period as further staff were unit. recruited from Australia and the above and other countries. as most staff were on The response of Red Cross 6-month contracts. The League (now the International Federa­ tion) of Red Cross and Red Crescent Societies based in Geneva appealed to its The patients member societies to send nurses, physio­ During the first 10 months 42 victims of the therapists and doctors to form a rehabili- earthquake were admitted to the unit. All Paraplegia 31 (1993) 16R-171 A spinal injuries unit in Armenia 169 were paraplegic. Fifteen patients with minor patients and their relatives coming to the paralysis were rehabilitated in a short period centre expecting cure, as before the estab­ of time and discharged. Twenty-seven had lishment of the unit the contemporary treat­ severe paralysis. For the majority, initial ment of rehabilitation of spinal cord injuries treatment had been laminectomy, which in a was unknown in the Soviet Union. The number of cases had led to further destabil­ philosophy of rehabilitation had to be ex­ isation of the spine causing gross deformity. plained to the patients and the Armenian It was possible for a number of these staff at the hospital with the help of inter­ patients to have spinal surgery to correct the preters who were university students spe­ deformity performed in Yerevan by visiting cially recruited for the purpose. American surgeons, but the deformity was Additionally, all patients had suffered so severe in 2 patients that they had to be severe psychological trauma from the earth­ transferred to Germany and the USA quake -from deaths of close family and respectively for surgery. Twenty-six patients friends, loss of homes and jobs, loss of were admitted with grade 3-4 pressure income, as well as personal injury to spine sores, 2 of whom eventually died from and spinal cord, and severe crush injury. severe sepsis present on admission to the Once the patients were ready to be unit. discharged back into the community major Thirty other spinal cord injured patients difficulties were encountered with housing, were also admitted in this period. These had as most of the patients had lost their homes become paralysed through the usual causes in the earthquake. The massive task of such as road traffic accidents, falls etc, 10 building both temporary and permanent before the earthquake and 20 after. housing for such a large number of people, quite apart from the need for specially adapted housing for the disabled, was a Establishment of the unit major problem in the first year after the The unit was housed in a renovated 24-bed disaster, and has continued to be so. There ward. All equipment, including beds and was little understanding of the needs of mattresses, wheelchairs and cushions, disabled people on return to the commun­ drugs, dressings, and urinary equipment had ity, not only with regard to housing but also to be supplied from other countries. with return to school or work. The special An area in the basement of the hospital needs for access by disabled people in the was allocated as a physiotherapy gymnas­ community were concepts unknown in the ium. Arrangements were made to have Soviet Union. some equipment flown in from outside the A visiting programme was established. It Soviet Union and for other equipment to be had two aims. One was to assist with finding manufactured locally. housing and advising the authorities of After the initial phase of management, building standards for disabled access. The which was predominantly concerned with other was a visiting nurse service. To these treating complications such as pressure was added an outpatient review programme sores, and included the surgical repair of a from the eighth month of the unit's exist­ number of the pressure sores by visiting ence. American surgeons, a more active rehabil­ itation phase was introduced. Because of the low level of injury in many of these patients there was a major need for orthoses Planning for the future for gait training. Various improvisations It was apparent from the time of the were used for some months until it was establishment of the unit in March 1989 that possible to establish an orthotics depart­ there was an obvious need for a perman­ ment 9 months after the earthquake. ently established spinal unit in Armenia. To Other difficulties with the fledgling accomplish this would require training of rehabilitation programme included the local health professionals and preferably the psychological reaction, with most of the building of a new purpose built unit. 170 Burke et al Paraplegia 31 (1993) 168-171

The training of Armenian staff began Armenians have been trained as rehabilita­ soon after the establishment of the unit. A tion therapists, combining trammg in lack of interest amongst trained nurses at rehabilitation physiotherapy and in occupa­ the hospital led to a decision by the Minister tional therapy. There are also three trainees of Health to allocate a group of 20 new in orthotics under the supervision of a nursing graduates to the unit, and these German orthotist. young people began an apprenticeship type As the Institute of Physiotherapy was of learning programme, working alongside considered to be inappropriate as a perman­ the Red Cross nurses on the same day and ent unit, plans for a new purpose built unit night shifts. were developed with the assistance of a Within a few weeks of opening the unit a group of German architects with advice young doctor (4) was seconded to work from Professor Paeslack from Heidelberg, alongside the first of the team leaders. This Germany. An 8-bed acute care unit was doctor has worked with all of the subse­ incorporated in the new 116-bed rehabilita­ quent team leaders and in 1990/91 spent 5 tion unit. Half of the beds in the unit are for months receiving more advanced training in medical rehabilitation, the remainder for the Spinal Injuries Unit of the Austin professional (vocational) rehabilitation. Hospital, Melbourne. Two other young The centre opened on 28 August 1992 and doctors, (5) and (6), were recruited in 1989 further training of Armenian staff, particu­ and 1990 and have similarly received on the larly in the acute unit, will need to continue job training. They too have received more with the assistance of expatriate staff over advanced training for 6 months each, in the next 12 months. Details of the training Germany and the Netherlands. A fourth of Armenian staff and the opening of the doctor, with a background in internal medi­ new unit will be the subject of a further cine, joined the group in 1992. paper. A group of young specialist surgeons was also introduced to the management of spinal injury patients by working part-time along­ Outcome of treatment programme side the team leaders. It was considered important that a neurosurgeon, urologist. At the end of December 1989, of the 42 orthopaedic surgeon and plastic surgeon patients admitted to the unit as a result of should also have the opportunity of spend­ injuries sustained in the earthquake, 40 ing some time in established units outside were still alive. It is understood that all have the former Soviet Union for more advanced survived to the present. Twenty-one pa­ training in the special surgical techniques tients regained normal bladder function, 9 required in the contemporary management were catheter free, 8 were on intermittent of spinal cord injuries. self catheterisation, and 2 had suprapubic Physiotherapists were initially more diffi­ catheters. Twelve of the patients were walk­ cult to recruit, though their interest in ing without aids. 21 walking with aids, and learning the rehabilitation techniques from only 7 were confined to wheelchairs. the Red Cross therapists was evident. The difficulties in training Armenians to become occupational therapists and social workers Discussion was even greater because there were no equivalents to these disciplines in the Soviet Through the InitIatIve of the Red Cross a Union. spinal unit was established at short notice in The training programme has continued a country which had no rehabilitation facil­ under subsequent team leaders, and has ities. to help the victims of a major natural been progressively taken over by the disaster. In the 3 months between the Armenian doctors and the other staff who earthquake and the opening of the unit a have been trained by the expatriates. large number of severely paralysed patients Thirty-four Armenian nurses now work on acquired preventable complications, treat­ the unit, including the head nurse. Twelve ment of which formed the bulk of the work Paraplegia 31 (1993) 168-171 A spinal injuries unit in Armenia 171 undertaken during the first 3 to 6 months of Paraplegia (IMSOP) has much to offer the the unit. Also, an unknown but possibly young doctors who will be the leaders of the large number died without getting to the new spinal unit in Armenia, by giving unit. opportunities to them and their staff to visit The major lesson to be learned from this other established units and by visiting the hastily established unit is that every country centre to lecture and teach. It is hoped that needs an adequately equipped and staffed this centre will act as a model for similar specialist spinal unit for the treatment and centres to be developed in other countries of rehabilitation of patients sustaining the the Commonwealth of Independent States. usual random spinal cord injuries. Such a We note also that the International Feder­ unit would have the ability to immediately ation of Red Cross and Red Crescent expand its services in the event of a natural Societies is developing a spinal cord unit in disaster or war, to cope with a sudden influx Bucharest, the capital of Romania. Nurses, of many new patients. Valuable resources physiotherapists and occupational therapists would not be consumed in the treatment of are urgently needed to establish training preventable complications, and rehabilita­ programmes for local staff. We urge mem­ tion of patients would not be delayed as it bers of IMSOP to encourage experienced was in Armenia. Another important lesson staff to help this worthy humanitarian pro­ is that death and injury from earthquakes ject also, as well as encouraging staff to can be minimised by safe building practices. volunteer to work in Armenia during 1992 The small number of deaths from an almost and 1993 to complete the training pro­ identical earthquake in San Francisco in gramme. 1990 compared to Armenia where over A new spinal unit has emerged in 3 years 25,000 died in poorly constructed high rise from the ashes of a terrible natural disaster. buildings, illustrates graphically the value of It has been a remarkable, cooperative effort preventative measures. by hundreds of people from all over the The International Medical Society of world.