Humanitarian Operations and Aid Agency Anesthesia Chapter 41 HUMANITARIAN OPERATIONS AND AID AGENCY ANESTHESIA † ‡ LAURA L. ROBERTS, MD*; JEYASANKAR JEYANATHAN, MBBS ; JOHN H. CHILES, MD ; AND PETER F. MAHONEY, OBE, MBA, FRCA§ INTRODUCTION Humanitarian Assistance as an Additional Mission Humanitarian Assistance as a Primary Mission Humanitarian Assistance Supporting Disaster Relief HUMANITARIAN ASSISTANCE MISSIONS: A GENERAL OVERVIEW Hospital Ships Mission Overview and Process Disaster Relief Host Nations and Nongovernmental Organizations Medical Personnel Surgical Services PRACTICAL CONSIDERATIONS FOR THE ANESTHESIA PROVIDER Preoperative Assessment Intraoperative Anesthesia Management Postoperative Care Considerations AUSTERE AND RESOURCE-LIMITED ENVIRONMENTS Anesthesia Techniques Postoperative Care CONCLUSION *Lieutenant Commander, Medical Corps, US Navy; Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, 167 Ashley Avenue, Suite 301, MSC 912, Charleston, South Carolina 29425 †Major, Royal Army Medical Corps; Academic Department of Military Anaesthesia and Critical Care, Royal Centre for Defence Medicine, Research Park, Edgbaston, Birmingham B15 2SQ, United Kingdom ‡Colonel (Retired), Medical Corps, US Army; Staff Anesthesiologist, Department of Anesthesia, Fort Belvoir Community Hospital, 9300 DeWitt Loop, Fort Belvoir, Virginia 22060 §Colonel, Late Royal Army Medical Corps, Defence Professor, Anaesthesia & Critical Care, Royal Centre for Defence Medicine, Research Park, Edgbaston, Birmingham B15 2SQ, United Kingdom 447 Combat Anesthesia: The First 24 Hours INTRODUCTION Humanitarian Assistance as an Additional Mission Humanitarian Assistance as a Primary Mission Traditionally, the focus of military medicine has Outside of combat operations, military personnel been care of the wounded during combat operations. are also involved in primary HA missions. During While this continues to be the primary focus, military these missions assistance is provided to a local popu- personnel are increasingly involved in secondary lace by predominantly US forces in conjunction with humanitarian assistance (HA) efforts as well. The military operations and exercises.1 This assistance is distinction between a primary and secondary mission specifically authorized by Title 10, United States Code, is important. For example, in deployments such as the Section 401, and funded under separate authorities. United Nations Mission to Haiti, 1994–1996, and Op- Under these provisions, the assistance must fulfill unit eration Iraqi Freedom, 2003–2011, the focus of medical training requirements and is limited to (a) medical, care is in support of deployed troops and authorized dental, and veterinary care provided in rural areas civilians. HA is a secondary mission. Both Role 2 (the of a country; (b) construction of rudimentary surface US Army’s forward surgical teams and the Navy’s transportation systems; (c) well drilling and construc- Forward Resuscitative Surgical System) and Role 3 tion of basic sanitation facilities; and (d) rudimentary (the Army’s combat support hospitals, the Navy’s fleet construction and repair of public facilities.2 Since 2006, hospitals, and the Air Force’s expeditionary hospitals) primary HA missions have been conducted annually in medical units are outfitted to meet expected combat an effort to promote goodwill and the national interests trauma, their primary mission. Typically, these units do of the United States. These missions alternate between not have instruments and equipment sets for specialty countries in the Pacific region and Southeast Asia and surgery and are extremely limited in their ability to Central and South America. care for pediatric patients. Additionally, it is vital that HA efforts initiated in Humanitarian Assistance Supporting Disaster Relief theater be cleared through command surgeon chan- nels up to the health affairs attaché in the US embassy. In addition to planned HA missions, the US mili- Also, there must be host nation approval for these tary is also called upon to assist civilian authorities in projects consistent with the existing Status of Forces disaster relief (DR) operations both within the United Agreement between the two involved countries and States and in foreign countries. Interventions in the their allies. When approval is obtained for HA projects past decade include relief efforts in Southeast Asia and with security permitting, the initial approach following the tsunami in 2004, assistance following the should be to assist local medical authorities in local Hurricane Katrina disaster in 2005, and humanitarian hospitals. If required care is beyond the capability aid to victims of the Haitian earthquake in 2010 and of the local hospital, the next step is to arrange for the victims of the Japanese earthquake and nuclear evacuation to a suitable civilian institution in theater. disaster in 2011. Another option is to treat HA patients at the Role 2 Today, the US military provides HA in a variety of or 3 medical facility. It must be clear that in these situations. These missions differ in size, scope, and plat- circumstances, military trauma takes priority over form. They vary from targeted interventions that sup- HA patients and local civilians will be discharged port a larger combat operation to large-scale missions after postoperative recovery. In a few rare cases, ar- with a global outreach objective. In each of these situa- rangements may be made to evacuate a patient with tions, as with combat operations, anesthesia personnel a treatable medical or surgical condition outside of perform a critical role in assisting with the coordination theater, possibly to a medical center in the United and delivery of surgical and pain management services. States. This option requires close coordination at all Understanding that role and the circumstances unique levels and support of a nongovernment agency willing to the HA mission will better prepare the anesthesia to sponsor the patient. provider deployed on such a mission. HUMANITARIAN ASSISTANCE MISSIONS: A GENERAL OVERVIEW Hospital Ships USNS Mercy (T-AH 19) and USNS Comfort (T-AH 20). Built in 1976 as oil tankers, both vessels were later ac- Large-scale humanitarian operations are generally quired by the US Navy and converted to hospital ships. carried out aboard the military’s two hospital ships, USNS Mercy was put into service in 1986 and USNS 448 Humanitarian Operations and Aid Agency Anesthesia Comfort in 1987. The primary mission of these ships are transported by either boat or helicopter to the is to provide an afloat, mobile, acute surgical medical hospital ship. This allows for a review of information facility to the US military that is flexible, capable, and and compliance with preoperative fasting. Typically, uniquely adaptable to support expeditionary warfare. surgeries are scheduled until 1 to 2 days prior to de- Their secondary mission is to provide full hospital parture to allow for appropriate postoperative care services to support US DR and humanitarian opera- and discharge of all patients.6 tions worldwide.3,4 Both ships are capable of providing Role 3 care Disaster Relief including triage, resuscitation, transfusion, laboratory testing, radiology services (including computed to- In contrast to the HA mission, extensive advance mography and interventional procedures), dental care, planning is rarely possible when responding to a di- initial and definitive surgery, postoperative care, inten- saster. Consequently, maintaining a state of readiness sive care, and patient holding capacity. Each ship can and utilizing personnel trained for such missions is provide care to patients of all ages, with a total patient critically important in maximizing efficiency and de- capacity of 1,000 hospital beds (including 80 intensive creasing response time. care, 20 postoperative recovery care, 280 intermediate Other key differences with a DR mission include the care, and 120 light care beds), twelve operating rooms, level of urgency and types of injuries treated. The care and ancillary services similar to shore-based facilities. provided during an HA mission focuses on improving quality of life, whereas the goals of DR are saving life Mission Overview and Process and restoring basic services to the affected population. Medical treatment involves emergent care of trauma- HA annual missions (Pacific Partnership 2008 and related injuries, and surgical procedures are aimed at 2010 in the Pacific region and Southeast Asia, and Part- saving life, sight, or limb. Additionally, unlike the HA nership for the Americas 2007 and Continuing Promise mission, the emergent and chaotic nature of the disas- 2009 and 2011 in Latin America) range in length from ter situation leaves little time for patient evaluation. 4 to 6 months and occur between April and October. This, in particular, makes the process of patient triage The number of countries visited, the time spent in each an essential component in the overall DR operation. country, and the services provided depend on the over- Triage quickly prioritizes patients based on extent of all strategic plan as well as other factors such as bud- injury to ensure maximum chances of survival and the get, staffing, and mission duration. Once the budget, most efficient use of resources. staffing, and schedule are determined for a mission, During Operation Unified Response (2010) in Haiti, an initial planning conference is held. Members from little information was available