Rehab units on wheels could revolutionise the way spinal injuries acquired in natural disasters are handled, savings thousands of lives each year, clinicians have been told.
They might also be the catalyst to creating vital neuro-rehab care networks needed in many parts of the developing world, a leading expert believes.
Over 6,000 natural disasters between 2000 and 2017 killed two million people and injured a further three to five million.
Around 90 per cent of natural disaster deaths and 98 per cent of injuries affect people in developing countries.
Severe spinal injuries are a major cause of death at the time of the disaster – and also in the days and weeks that follow; often due to a total lack of rehab infrastructure within reach of the disaster zone.
In the Haiti 2010 earthquake, for example, more than 220,000 people were killed and 300,000 were injured.
A report published six months afterwards suggests there were only 150 people remaining in Haiti with earthquake-related spinal cord injuries – still an unprecedented amount in a nation not set up to offer adequate spinal injury care.
As one research paper on Haiti (Burns, O’Connell, Landry 2010) noted: “Some facilities decided not to treat catastrophic injuries, such as spinal cord injuries (SCI), because of the resource-intensive needs of these patients, perceived low survival rates, and ‘minimal chance of ultimate rehabilitation’.”
Severe injury rehab understandably sits far below the provision of shelter, food and basic medical care on government and NGO agendas immediately following disasters.
Its value in saving lives, and rescuing survivors from a lifetime of serious limitation, however, has not been overlooked by those shaping disaster relief development.
Among them is Jianan Li, a professor and chief doctor in rehabilitation medicine and president of the Chinese Society of Physical Medicine and Rehabilitation.
He recently shared China’s progress in disaster recovery at the World Congress for NeuroRehabilitation in Mumbai.
He said: “China has built up an emergency management system from a national network to all parts of the country. With natural disasters, the location and severity of injuries is unpredictable but certain rescue actions and disaster relief – including rehab relief – can be prepared.
“It’s very important to realise that rehab in natural disasters is very different from the normal rehab need.
“When any disaster happens, local medical personnel may be involved in the relief effort but may also be victims and local medical facilities may be damaged or destroyed. The most important task for the local government is not rehab but to provide settlement for survivors.”
“Institutional rehab is limited to acute and sub-acute stages, not the long-term.”
The magnitude eight earthquake which hit southwestern China in 2008 saw 11,028 hospitals and clinics destroyed, amid 87,150 fatalities and missing persons and 374,000 injuries.
An SCI was sustained by around 15 per cent of all patients admitted to their nearest tertiary care hospital.
A post-event study shows the possibilities of the type of long-term rehab many disaster victims in the developing world are not afforded (Y. Li et al, 2012).
It also highlights the importance of a speedy response to potentially catastrophic injuries in disaster zones.
It concludes that institutional-based physical rehab programmes for disaster-related SCIs may significantly improve functional outcomes. In the aftermath of that disaster, a national rehab team formed, made up of rehab professionals from institutions in other provinces.
The team provided rehab services to SCI patients and others in newly established rehab departments of three hospitals in the worst affected areas from two months to up to two years after the quake.
The study, which followed 51 severe SCI cases, shows 90 per cent resumed walking – most through KAFO (knee ankle foot orthosis).
Nearly everyone who needed a wheelchair was able to operate it independently following a rehab programme, while over 90 per cent regained some self-care ability prior to discharge.
Most victims (70.6 per cent) were rescued within 30 minutes of the disaster but only one patient began rehab therapy within a month – with most beginning two to four months afterwards.
“Rehabilitation effectiveness was found to be inversely related to time to rescue and time to rehabilitation,” researchers stated.
“Significant improvement in MBI scores [a measure of independence in daily tasks] with rehabilitation was achieved by groups that were rescued from the rubble within 30 mins and/or received rehab no later than three months after the injury; the group that was rescued and began rehabilitation relatively later showed the smallest improvement.
“These findings are consistent with common assumptions about neural plasticity and optimal windows of opportunities for rehabilitation.”
In other words, getting disaster victims on an adequate rehab programme quickly can have a dramatic impact on their outcome.
In China this is made more challenging due to the mountainous and remote nature of some areas – and the sheer vastness of the country; as highlighted in the SCI study’s findings.
Most of the SCI patients were discharged to mountainous, rural areas with poor roads, inaccessible public transport and non- inclusive homes, it reports.
In less developed countries, building the foundations for a post-disaster rehab programme is even harder – with facilities destroyed, poor infrastructure and a dearth of on-the-ground rehab skills.
Li’s proposed solution is the mobile rehab truck – a rehab unit on wheels which could be despatched to any disaster zone in the developing world.
He said: “It needs two very important things – manpower and equipment. It would need rehab equipment, but also medical equipment such as x-rays, ultrasound and so on. We would also need sleeping bags, tents and cooking facilities.
“It could be moved into the poorest and most remote areas which have no rehab facilities and help to build up their first rehab infrastructure. We would set up a hospital in the disaster zone and provide services for 13 months or longer.
“For example, if there was an earthquake in Nepal, we could go there and work on a rolling basis until it was needed somewhere else in the world. The mobile hospital could take another vital resource there – training. Professionals could train people working in the disaster zone and employees in the area.
“My dream would be to support it through an NGO comprised of industries, charity organisations, academic bodies and even some hospitals.”
Li is hopeful that there will be enough global interest in the idea to gain the support needed to get it motoring in the not-too-distant future.
Another useful addition to post-disaster rehab will be further advancements in telemedicine, believes Raju Dhakal, who also spoke at the World Congress in Mumbai.
Dhakal is medical director of the Spinal Injury Rehabilitation Center (SIRC) Nepal and a leading authority on spinal injury rehab in disaster zones.
He was part of the team that helped to treat spinal injuries in the aftermath of the Nepal 2015 earthquake, which killed 9,000 and injured at least 22,000 people.
Working out of SIRC – supported by spinal injury experts via telemedicine – 81 SCI patients were admitted for comprehensive care by a multidisciplinary medical rehabilitation team within four weeks of the disaster.
Special cases, including a third trimester pregnancy with incomplete unstable spine fracture, undiagnosed SCIs in children, misdiagnosed spine fracture, SCI with stroke and SCI complications linked to associated injuries, were all well managed through tele-consultation.
A study into SIRC’s work found that: “Tele-consultation through various means such as telephone, e-mail, and video conferencing can improve the quality of healthcare by aiding in diagnosis and management of patients, and to train healthcare professionals.
“The accessibility of specialty and subspecialty expert care can reach a larger population base thereby reducing the morbidity and mortality after SCI and eventually increasing quality of life. Information technology and modern portable communication devices should be incorporated in disaster preparedness and post-disaster SCI rehabilitation.”
Dhakal said: “At the time of the earthquake our centre had no standard telemedicine systems. Often the internet and phone lines weren’t working and sometimes we had to work very slowly, with lots of disconnections.
“Despite these problems, telemedicine really helped with patient care and rehabilitation.
“The advantages of telemedicine are that there are no visas required for experts – and no travel problems or risky trips for professionals to earthquake zones. It also increases international links between healthcare experts.”
Also speaking at the World Congress was Angela Tulaar, a disaster rehab expert working in Indonesia – where there is a near-constant threat of volcanic eruptions, earthquakes, floods and tsunamis due to its position on the Pacific Ring.
She provided detailed context of the challenges facing rehab staff in disaster zones. After particularly devastating earthquakes she had seen spinal injury patients having to lie on floors or in hospital car parks awaiting treatment, such is the burden disasters can put on local infrastructure.
She concluded: “To plan for disasters you first must gather enough information and send the advanced team in as early as possible – then set up short and long-term goals, recruit staff and list the equipment needed.
“And, you must implement community-based rehab through which education and training is very important.”