Challenges in Delivering Rehabilitation in Disasters and Conflicts

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Introduction

Disasters and conflicts often result in damaged infrastructure and disrupted health systems and often occur in remote, underserved areas. In many cases, people are displaced or live in temporary shelters with limited provision for those with disabling injuries, especially when they have impaired mobility. Rehabilitation professionals face unique challenges when working in these settings associated with complex trauma, injury surge and resource scarcity in terms of equipment, infrastructure, and workforce that occur on an unprecedented scale and outstripping available resources. Rehabilitation professionals are well placed to address these challenges and can add considerable value to patient care. Furthermore, by assisting in discharge planning and identifying local providers for ongoing care, rehabilitation professionals can help ensure appropriate and efficient patient flow through an Emergency Medical Teams. Understanding and recognising these challenges is vital for rehabilitation professionals to be able to navigate the demands of the emergency medical response in disaster and conflict settings.

Overwhelming Patients and Prioritisation

Disaster is a serious disruption of the functioning of a community or society, which involve widespread human, material, economic or environmental impacts that exceed the ability of the affected community or society to cope using its own resources. In the wake of a disaster or conflict health infrastructure and workforce can often become overwhelmed, particularly within the early days of the emergency response following a sudden onset disaster, where responders have to cope with an influx of mass casualties presenting to health services, or in conflicts and protracted crises with patients presenting over long periods of time with a persistent challenge of balancing  the needs of new patients requiring early rehabilitation and those with ongoing rehabilitation needs. Other issues also arise with this influx of which can further impact on rehabilitation needs including family separation, unaccompanied children, and destroyed homes resulting in displacement.

Both of these situations brings significant challenges for the medical team and rehabilitation professional as it is not always possible to treat everyone optimally, and ability to prioritise become vital given the tremendous imbalances between supply and demand for care. Rehabilitation professionals need to both prioritise who they treat and consider their interventions in order to maximise the limited time they have with patients, and ensure the best possible carry over within the constraints of the environment. The field handbook, Early Rehabilitation in Conflicts and Disasters suggests the following priorities for provision of early rehabilitation to enable best possible outcomes and minmise complications;

1. Patients whose life may be at risk without rehabilitation input, e.g. new suspected spinal  injuries, brain injury or patients in need of urgent respiratory input.
2. Patients who are likely to quickly develop complications without rehabilitation input, e.g. patients with spinal injuries, or burns  
3. Patients who may be facing early discharge or who can potentially be safely discharged from acute care with rehabilitation input, such  as patients requiring assistive devices, education and a follow-up appointment (e.g.  patients with an upper limb or lower limb fractures following surgical management)
4. Patients whose conditions will be quickly improved through rehabilitation input or  who might be at risk of slowly developing complications, such as patients with new  amputations, patients on traction and patients with brain injuries.

There is now recognition that early rehabilitation can facilitate earlier discharge from hospitals thereby improving the overall capacity to treat a higher number of patients. Interventions that have the most value in coping with the needs of large numbers of patients include patient and caregiver education around management of the condition and recognition of complications and what to do if they occur so that they can self-mange on discharge. Active treatments including positioning, exercises and functional activities are the key interventions to also support management with a focus on being able to do activities of daily living.

International Support

While international support often has a role to play, it can create challenges for local responders, with lack of coordination with and amongst disaster management organisations common,which draw time and resource away from a local response, particularly is international responders are only staying for short periods of time. According to Cranmer and Biddinger “poorly prepared and poorly equipped responders have sometimes ended up depleting needed resources rather than providing solutions. In previous emergency responses, some health care workers have worked outside their scope of practice and licensure. Many have been deployed without food, water, medical-supply chains, or even transportation. Their failure to secure basic logistic arrangements taxes already stressed and fragmented local systems that are attempting to deliver basic necessities to the locally affected population. Failure to coordinate with local response authorities or with international relief agencies results in either duplication of existing capacity or missed opportunities to fill gaps in delivery.”

Individuals should only ever travel to disaster zones as part of an established international organisation or as a member of an Emergency Medical Team that is registered as part of the World Health Organisation and are aware of minimum technical standards for rehabilitation in emergencies and should only travel at the request of a locally based organisation. Emergency Medical Teams are now considered a vital aspect of the global health workforce that provide direct clinical care to people affected by disasters and conflicts and support local health systems, particularly in disaster and conflicts where local health workforce have been decimated and health infrastructure significantly damaged or destroyed.

Injury Complexity

The type and distribution of injuries caused by disasters and conflicts varies widely according to the type of hazard and a range of other factors. In general though, complex poly-trauma are common with a range of injuries including fracture, limb amputation, spinal cord injury, traumatic brain injury, peripheral nerve injury and burns, that often have to be managed concurrently, which can complicate both your rehabilitation assessment and intervention.

The Minimum Technical Standards and Recommendations for Rehabilitation - Emergency Medical Teams outline the following recommendations around injury complexity in emergencies.

• Recommendations for Optimal Care;
  • Rehabilitation professionals with an arriving team should be experienced in trauma and medical rehabilitation with experience and/or training to work in austere environments.

Clinical Expertise

Trauma specialist with extensive experience of major trauma, and other Clinical Specialist in complex conditions such as spinal cord injury, traumatic brain injury and burns tend to be in short supply in these settings. Given the complexity of injuries seen in disaster and conflicts with the massive surge of patients presenting with poly-trauma, rehabilitation professionals who are going to work in these settings need to be skilled across multiple clinical areas to manage the complexity and should have had adequate training to ensure that they have the core clinical skills to be able to manage a wide range of presentations in a challenging environment. Specialised care teams, such as those for spinal cord injury, burns, and orthoplastics, may also be required to augment local rehabilitation capacity and provide specialist rehabilitation care.

Rehabilitation professionals with specific expertise may have a role in the training and up-skilling of local rehabilitation professionals. This should only be considered where adequate supervision and support will be available to support them in developing and integrating those new skills in to their practice. Blanchet and Tataryn have previously reported that short-term volunteers did not help improve the training, knowledge or clinical practice of local staff. Due to the high turnover rate of volunteers and lack of continuity of practices between the different organisations, there was little uptake of new skills or techniques. Consequently, local staff resorted to what they already knew to avoid confusion between the disparate approaches of transient volunteer teams.” So where staff experienced in major trauma are involved in training they should be based within Specialised Emergency Medical Teams that spend longer in the field to ensure carry over into practice occurs.

The Minimum Technical Standards and Recommendations for Rehabilitation - Emergency Medical Teams outline the following recommendations around clinical expertise in emergencies.

• Recommendations for Optimal Care;
  • Rehabilitation professionals with an arriving team should be experienced in trauma and medical rehabilitation with experience and/or training to work in austere environments.
  • Rehabilitation professionals should comply with the same requirements for practice as in their home country and should work within their scope of practice.

Challenging Environment

In large-scale disasters, particularly where there has been significant damage to infrastructure, patients are often treated in a wide variety os settings, and it is not unusual to be treating acute patients outside of acute wards, including in hospital corridors, overflow tents in car parks or tents in formal or informal camps. Multi-disciplinary team (MDT) support is  likely to be more limited in these situations, and risks to patients are further magnified if they  face limited monitoring, or lack an appropriate bed. Patient treatment and education need to be  adapted, in particular for patients being managed on the floor, and manual handling needs to be  adapted to protect patients, caregivers and staff.

Access to Equipment

Essential assistive technology, such as wheelchairs, crutches, splints and orthotics are often in short supply during the immediate response and can significantly limit rehabilitation interventions . This lack of assistive technology affects not only those with new injuries but also those who may have displaced or damaged assistive technology as a result of the disaster or conflict which can all can create bottlenecks in acute centres, result in prolonged bed rest, limit early mobilisation or delay discharge home, which further impacts on rehabilitation capacity.

In many instances rehabilitation professionals may be involved with the provision of mobility devices, where available, to enable safe discharge. Sometimes, temporary mobility devices are necessary for purposes such as facilitating smooth, timely discharge. In these situations, the devices should be configured to the user’s needs as closely as possible meaning it fits them, can be self-propelled (if the person is capable) and can be used in the local terrain. Many patients following injury may require an orthotic, prosthetic device or wheelchair long term, so it is important that these devices should be safe, durable, affordable and maintainable in the country of use and should meet the user’s requirements and environment, with a a proper fit, alignment and support that meets sound biomechanical principles. As with any assistive technology, mobility devices should always be provided with appropriate, and for those who require long term use local services should be involved in prescription so that they can adapt them to the local context and remain available for follow-up, including maintenance and or replacement.

For Emergency Medical Teams, both national and international, the minimum standards for rehabilitation highlight equipment that is essential and non-essential but recommended for initial deployment; however, these standards are minimum and aimed  at field hospitals and so may not always be directly transferable to fixed trauma or rehabilitation facilities.

The Minimum Technical Standards and Recommendations for Rehabilitation - Emergency Medical Teams outline the following recommendations around assistive technology in emergencies.

• Recommendations for Optimal Care;
  • Emergency Medical Teams should bring the essential equipment and consumables for their type when they deploy, so that they can be self-sufficient for at least the first 2 weeks of response. Alternatively, they should have a documented agreement with an organization to provide this equipment rapidly in the event of deployment.

• Recommendations for Optimal Care;
  • Emergency Medical Teams are encouraged not to expect that equipment will be provided by the host country.
  • Rehabilitation materials should be carefully selected according to the anticipated need, team capacity, local needs and expected case-load.
  • Wheelchairs, orthotics and prosthetics for long-term use should be obtained from a local supplier, where one is available; otherwise, the Emergency Medical Teams should seek guidance from the host ministry of health/coordination cell.
  • Emergency Medical Teams should maintain an inventory of equipment and consumables and plan for their replenishment on the basis of their case-load and length of stay.

Discharge Planning

The coordination of inpatient discharge planning and follow-up is still one of the greatest  challenges in emergency settings, especially where patients have been transported from  remote areas, or if their homes have been destroyed. Due to hospitals being overwhelmed,  further anticipated surges or insecurity, patients may need to be moved from an acute setting  as soon as possible, therefore it is important to consider the following points:

1. Early discharge of acute patients

A lack of bed spaces may lead to earlier than expected discharge; sometimes as soon as a  patient is stable post-operatively. Short stays in hospital and limited possibilities for follow up place increased pressure on initial rehabilitation sessions, and again emphasise that  patient and caregiver education, maintaining a database and considering follow up plans  are all critical in the early stage, otherwise patients are lost to follow-up. Even for expected  longer-stay patients, it is still important to make discharge plans early, as emergency settings  can be unpredictable. Establishing rehabilitation criteria and emergency care pathways in  advance of an event can help to limit patients being discharged to an unsafe environment.  During an emergency rehabilitation professionals may have a role in advocating for patients  to remain in health facilities if they are being placed at risk by being discharged.

2. Challenging discharge destinations

Think about where your patient is being discharged to. This could be (amongst other  things) their home, a displaced people’s camp or shelter, a step-down facility or to stay  with friends or family. They could be travelling several days, or staying alongside the  hospital. Examples of the challenges patients face on discharge in emergency settings  include sleeping on hard floors, camps being severely inaccessible, not being able to  access aid distributions, a lack of caregivers, inaccessible toilet facilities and patients  not being able to return for follow-up due to distance, cost or availability of transport. If  patients are commonly being discharged to camps, try to find out what the environment  is like. This will help you to problem-solve and set up appropriate treatment plans before  they are discharged.

3. Family and/or community support

Be mindful that there may be a lack of family/community support, as those affected by  the conflict/sudden onset disaster may have also lost their own families, friends, homes  and livelihoods. Pay particular attention to unaccompanied children, people with existing  disabilities and older people (see the vulnerability section below).  

4. Follow-up

Disasters often affect rural and isolated communities; transport infrastructure and  terrain, which may make accessing medical care (and in particular follow-up care and  rehabilitation) difficult. Critically injured patients may be evacuated to more central urban  centres for treatment, but wish to return home as soon as possible. Similarly, it is rare  to provide rehabilitation for civilians on the frontline in conflicts. More often, patients are  stabilised and then transferred for further care, but their length of stay in facilities is often  short, and safety and security challenges can make follow-up a challenge. This is further  complicated in situations of displacement, where populations are on the move, creating  huge challenges in ensuring continuity of care. Ideally, a patient will be followed up by  the hospital that carried out their main treatment, but in emergencies this is not always  possible. In the early days, there will be uncertainty about what services and facilities  are available to patients needing long-term rehabilitation. Often, private services are  made available free of charge, but may later revert to being charged for. Do not make  assumptions or unqualified promises to patients about access to services in the future.  Community follow-up can also be a challenge, due to safety and security issues and the  sheer volume of patients. For international teams, such as EMTs, follow-up can be even  more challenging, especially if the length of stay of the team is limited or unknown.  

5. Onward referral to other rehabilitation services  

Rehabilitation professionals should play a role in making sure that patients who have  rehabilitation needs are identified, and referral mechanisms are established. This  would include linking emergency response services with hospital and community based rehabilitation facilities. Appropriate follow-up is key to successful patient  outcomes, therefore coordination should be done through existing mechanisms to  avoid duplication. In large emergencies, this may be done through the Health Cluster  or the EMT coordination cell. Recently, the inclusion of rehabilitation specialists in  overall coordination (such as in Nepal in 2015 and Mosul in 2016) has included referral  pathways and hotlines being coordinated centrally, so it is critical for rehabilitation  actors to engage with coordination. Where local services are unable to meet demands,  INGOs are likely to be establishing services, and so being aware of all actors involved  in the response is important.

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