BJA Education, 17 (1): 22–27 (2017)

doi: 10.1093/bjaed/mkw028
Advance Access Publication Date: 14 May 2016
Matrix reference 1I02, 2A07,
2A12, 3A10, 3I00

Disaster management in a low-resource setting: the role

of anaesthetists in international emergency medical

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teams
M Walmsley BMed1 and P Blum MBBS FANZCA2,*
1
Senior Registrar, Department of Anaesthesia, Royal Darwin Hospital, Mt Everest Base Camp Doctor, Himalayan
Rescue Association, PO Box 41326, Casuarina, NT 0810, Australia and 2Deputy Director, Department of
Anaesthesia, Royal Darwin Hospital, PO Box 41326, Casuarina, NT 0810, Australia
*To whom correspondence should be addressed. Tel. +61 8 8922 8713; Fax: +61 8 8922 8325; E-mail: philip.blum@nt.gov.au

Key points
• Hundreds of millions of people are affected by
sudden-onset disasters (SODs) each year.
• Anaesthetists, as members of international emer-
gency medical teams (EMTs), are called upon to
assist low- and middle-income countries experien-
cing a disaster event.
• Previous disasters have seen some teams arriving un-
prepared and unable to provide effective assistance.
• There is increasing focus on the professionalism of
EMTs.
• Health providers need to undergo training specific
to working in the austere environment of an SOD.
Sudden-onset disasters
A disaster can be defined as a serious disruption to the function-
ing of a community. SODs occur with little or no warning, leaving
insufficient time for the vulnerable population to be evacuated.
There are widespread human, material, economic, and environ-
mental impacts on the social and cultural wellbeing of the com-
munity.2 The scale of the impact exceeds the ability of the
affected community to cope using its own resources. Outside
teams are often called upon for assistance.
Type of disaster
The overall disaster assistance required, and also the specific
medical needs, will vary in accordance with the type of natural
disaster (Table 1).

Sudden-onset disasters (SODs) such as earthquakes, tsunamis,
and tropical storms affect millions of people annually. Over the
past 20 yr, there has been an increase in both the number of nat-
ural disasters and the number of people affected by them, with
268 million people affected annually between 2002 and 2011.1
The number of international medical teams responding to such
disasters has also increased.1 Anaesthetists may be part of an
emergency medical team (EMT) working in a low- or middle-in-
come country in the aftermath of a severe event. In recent
years, there has been a focus on ensuring such teams are ad-
equately prepared and respond to disasters with appropriate re-
sources, training, and expertise.
Earthquakes
Earthquakes may cause many deaths and injure a large number
of people, often due to destruction of homes. The number of cas-
ualties will depend on the type of housing, the time of day of the
earthquake, and the population density. Secondary threats exist
in the form of flooding, landslides, and contamination of water
supplies. The mortality is usually greatest closest to the epicentre
and the demand for both search and rescue and emergency
health services is great during the first 24–72 h. Survivors often
have complex ortho-plastic peripheral limb trauma. For example,
an analysis of 3177 injuries suffered during the 2008 Wenchuan
earthquake in China found that 46.5% of the injuries were
fractures.3

© The Author 2016. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved.
For Permissions, please email: journals.permissions@oup.com

22
 Disaster management in a low-resource setting

Table 1 Expected health effects of a natural disaster6

Effect Type of disaster

Earthquakes Tropical Tsunamis/ Slow-onset Landslides Volcanoes

storms flash floods floods

Potential deaths in the Many Few Many Few Many Many

absence of preventive
measures
Severe injuries requiring Many Moderate Few Few Few Few
extensive treatment
Increased risk of Potential risk after all major disasters ( probability increasing with overcrowding and deteriorating sanitation)
communicable diseases
Damage to health facilities Severe (structure and Severe Severe but Severe Severe but Severe (structure
equipment) localized (equipment localized and equipment)
only)

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Damage to water systems Severe Light Severe Light Severe but Severe
localized
Food shortage Rare (may occur due to Common Common Rare Rare Rare
economic and logistic
factors)

low-lying populations. Contamination of water supplies may

lead to outbreaks of infectious diseases such as cholera.

Volcanic eruptions
The timing of volcanic eruptions is unpredictable. Populations
often settle in close proximity to volcanoes as the volcanic soil
produces ideal agricultural conditions. Volcanic eruptions can
cause complete destruction of everything in the path of super-
heated gas, ash, mud, or lava flows. Fractures are common and
are caused by falling rocks and other debris and building collapse.
Other injuries include burns and respiratory difficulty caused by
gas and ash.

Landslides
In general, landslides cause high mortality, but relatively few in-
juries. Health structures in the path of the landslide may be se-
verely damaged or destroyed.5 6

Timing of need for medical services post-SOD

Fig 1 Cyclone storm surge: reproduced with permission from the Australian
Bureau of Meteorology.4
Tsunamis and flash floods
Tsunamis and flash floods cause many deaths but leave relative-
ly few severely injured. Most deaths are caused by drowning. In-
juries occur from battering by debris and searching through
damaged buildings for belongings or loved ones. Structures and
infrastructure including healthcare facilities, and also crops, live-
stock, and fishing boats, can be damaged.
Tropical storms
Tropical cyclones (also called hurricanes or typhoons depending
on geographical location) cause relatively few fatalities, but there
may be numerous casualties requiring hospital treatment. Injur-
ies are usually caused by flying debris. Tropical cyclones may
cause an increase in sea level, known as a storm surge4 (Fig. 1).
The storm surge can be particularly destructive and increase
the death toll significantly, similar in effect to a tsunami on
The need for emergency trauma surgery will be greatest in the
initial 48 h after an SOD. It is in this time period that life and
limb-saving treatment from injuries caused directly from the
SOD can be performed. This early treatment, such as manage-
ment of major head, chest, and abdominal injuries, is performed
using local resources or EMTs from neighbouring countries.7 8
During days 3–5, the need for follow-up medical care, such
as treatment of trauma complications and wound infections,
will increase. Presentations as a direct result of the disaster
decrease.7 8 Medical, obstetric, and surgical emergencies unre-
lated to the disaster add additional burden to a damaged and
stressed healthcare system. Unmet elective surgical and other
healthcare needs will accumulate in the weeks after the disaster
event. The delivery of healthcare may be further hindered by in-
jury or loss of local healthcare workers.7 8
In 2003, the WHO-PAHO published guidelines for the use of
foreign field hospitals (FFHs).7 Three uses were identified, corre-
sponding to the timing of healthcare needs: early emergency
care, follow-up care, and acting as a temporary healthcare facil-
ity. Essential requirements, such as self-sufficiency, appropriate
standards, and time frames to become operational were given.

BJA Education | Volume 17, Number 1, 2017 23

Disaster management in a low-resource setting
However, deployment times in recent SODs have been much
longer than these recommendations. For example, the peak
number of operational EMTs after the 2013 Typhoon Haiyan in
the Philippines occurred 22 days after the storm. The average
time from team arrival to commencement of activities was
3 days.9
Emergency medical teams
EMTs are groups of health professionals and supporting staff
working to provide healthcare to disaster affected populations.
An FFH is a mobile, self-contained, and self-sufficient healthcare
facility. It should be capable of rapid deployment and able to
meet emergency requirements for a specified period of time. It
can be set up in an existing structure or in a temporary structure
such as a tent, brought into the country by the EMT.2
After an SOD, a large number of international medical teams
can arrive in the country to provide emergency care. Experience
has shown that in many cases, medical team deployment is not
based on appropriate needs assessment. There has been a wide
variation in team experience, competence, and adherence to
professional ethics. The Sphere project was launched in 1997 by
a group of humanitarian NGOs and Red Cross and Red Crescent
workers.4 This project recognizes and promotes minimum
standards across all areas of humanitarian aid—water supply,
sanitation, and hygiene; food security and nutrition; shelter,
settlement, and non food items; and health action.10
Despite these early guidelines, disasters such as the 2004
tsunami in Indonesia and 2010 Haiti earthquake continued to
see well intentioned but poorly equipped responders with a
limited skill set arriving uninvited, without adequate food,
water, transport, and medical supplies. Some teams were unvac-
cinated and both physically and psychologically unprepared.11
This placed an additional and unnecessary burden on a country
already struggling to provide basic necessities for its own
population.
The Haiti earthquake demonstrated a wide range in clinical
practice, most notably limb amputation surgeries ranging from
<1% in one FFH to over 45% in another. Stump revision surgery
was required in 30% of amputees, compared with a rate of around
5% in high-income countries.12 Some medical practices per-
formed during the Haiti earthquake have been labelled a ‘medical
shame’. There were reports of ‘disaster tourists’ performing
inappropriate procedures on patients who were inadequately
consented and lacked appropriate psychosocial support and
follow-up.13
The World Health Organization (WHO) convened a Foreign
Medical Team Working Group in response to issues raised after
the Haiti earthquake. The resulting document, a Classification
and Minimum Standards for Foreign Medical Teams in SODs, was
published in 2013.2 This document sets out, for the first time,
minimum standards for EMTs, and classifies them into three
types, with a mandatory set of requirements for each (see
below). The classification system focuses on the type of service
provided by the EMT rather than the physical structure in
which the services are provided.2 International EMTs wishing
to work with the WHO during SODs agree to comply with this
set of standards and principles. Minimum standards cover all
facets of hospital function, including staffing, equipment, in-
patient and outpatient capacity, sterilization, diagnostic services,
record keeping, and audit.
There is now a greater focus on the professionalization of
disaster response and teams are required to be adequately
prepared and trained to function in a resource-limited setting.
24 BJA Education | Volume 17, Number 1, 2017
International standards for safe practice of anaesthesia have
been published and should be followed by international
EMTs.14 There is also an increasing focus on research, quality
and safety, accountability, and transparency. However, account-
ability continues to be both poorly defined and poorly enforced
among health providers.1
EMTs are classified according to their level of care, capacity,
and capability.
EMT type 1: outpatient emergency care
A type 1 EMT is an outpatient only service that is able to provide
initial emergency care of injuries and other significant healthcare
needs. It should be capable of: triage, assessment, and first aid;
stabilization and referral of severe trauma; and definitive care
for minor injuries. Type 1 EMTs are open during day-time hours
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and should be able to assess a minimum of 100 patients per day.
As they are light and portable, the team should be able to arrive in
the fastest time possible—ideally within the first 24–48 h and be
prepared to stay for at least 2–3 weeks.2
EMT type 2: inpatient surgical emergency care
A type 2 EMT provides acute inpatient surgery, obstetric, medical,
and paediatric care. The team should be able to provide: surgical
triage, assessment, and advanced life support; definitive wound
and basic fracture management; damage control surgery;
emergency general and obstetric surgery; inpatient care for
non-trauma emergencies; basic anaesthesia, X ray, blood trans-
fusion, laboratory, and rehabilitation services.
Type 2 EMTs should be able to provide after-hours services
and have a minimum of one operating theatre and 20 inpatient
beds. The team should be able to perform at least seven major
or 15 minor operations per day. Type 2 EMTs are useful from
day 1 post-onset of disaster but in reality may take several days
to become operational in the field. The team should be available
to stay for at least 3 weeks.2
EMT type 3: inpatient referral care
A type 3 EMT provides complex inpatient surgical care and in-
cludes an intensive care unit (ICU). In addition to type 2 services,
it is able to provide: complex reconstructive wound and orthopaed-
ic care; more complex paediatric and adult anaesthesia; intensive
care with 24 h monitoring and ventilation; and high level radiology,
blood transfusion, laboratory, and rehabilitation services.
The facility should be open both day and night and have at
least two operating theatres, 40 inpatient beds, and four to six
ICU beds. The theatre team should be able to perform a minimum
of 15 major or 30 minor operations per day. Type 3 EMTs should
be offered immediately and deploy without delay, but are unlike-
ly to be operational in the field for at least 1–2 weeks. Owing to
their role in receiving referrals and managing complex cases,
the service should deploy for a minimum of 2 months.2
Additional specialized care teams
Additional specialized care services may be provided within
a type 2 or 3 EMT. Examples include: burn care, dialysis, maxillo-
facial surgery, orthoplastic surgery, intensive rehabilitation,
maternal health, and neonatal and paediatric care.2
EMT preparedness
A priority of sustainable aid should be to improve disaster pre-
paredness within low- and middle-income countries that are at
a high risk of natural disasters. As this need is unlikely to be
 Disaster management in a low-resource setting

adequately met, the need for international assistance will remain
a reality into the foreseeable future. In recognition of the great
unmet need for essential life-saving surgical and anaesthetic
care in low- and middle-income countries, the Lancet Commis-
sion on Global Surgery was launched in 2014. The report, pub-
lished in 2015, outlines five key messages to improve access to
timely, safe, and affordable surgical care by 2030. The report
noted that by integrating surgery into district hospitals, the hos-
pitals’ ability to provide other complex healthcare services is in-
evitably increased. Thus, by strengthening basic surgical care, a
hospital will be better equipped to deal with a range of health
challenges, including those faced in the aftermath of a natural
disaster.15
EMT staff
‘deployment ready’ criteria are set, such as pre-departure health
checks and vaccination, in country codes of conduct and a post-
deployment psychological debrief.5 11 16
Pre- and post-deployment psychological training and debrief
is recognized as an important part of both pre-departure pre-
paredness and in managing the homecoming phase of a mission.
EMT workers are exposed to stressful situations. This can range
from working in an unfamiliar environment and being faced
with ethically challenging situations to being exposed to critical
incidents such as a serious threat to one’s own life.5 The Antares
Foundation and the Centre for Disease Control examined stress
and adjustment disorders among aid and development workers.
Approximately 30% of international staff from five agencies sur-
veyed reported significant symptoms of post-traumatic stress
disorder on return home.17

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Health professionals and medical logisticians deployed to SODs EMT equipment and systems
must undergo specialized training in delivering care in austere Along with a prepared team, a cache of pre-packed medical and
and resource-poor environments. Ideally, they should have ex- personal equipment should be stored and ready to use immedi-
perience in areas such as disaster management, humanitarian ately. To enable EMTs to deploy promptly and to be maximally ef-
relief, public health, travel, and field medicine. fective on arrival, the practicalities of the day-to-day running of a
The UK International Emergency Trauma Register (UKIETR) self-sufficient field hospital should be planned well in advance.
Anaethesia Training for Austere Environments (AAE) and the This will include:5 18
Australian Medical Assistance Team Training (AUSMAT) run by
the National Critical Care and Trauma Response Centre • Means of power generation: for both hospital equipment and
(NCCTRC) are examples of essential pre-deployment courses. personal use, e.g. generators, batteries, solar devices.
These courses focus on issues such as safety and security, nego- • Equipment: should be portable, light-weight, and robust. It
tiation, transport, cultural awareness, team dynamics in the field, should have back-up battery capability for use in the event
stress management, ethical dilemmas, and familiarization with of power failure. Team members should be familiar with
equipment. The courses include high-fidelity simulations in equipment and have a plan to deal with malfunction. A
which team members are responsible for the set up of a field hos- means of sterilizing surgical equipment and providing per-
pital and management of casualties (Table 2). sonal protective equipment should be planned.
UKIETR and AUSMAT ensure deployed personnel are appro- • Oxygen supply: decision to use oxygen concentrators, oxygen
priately trained to meet international standards. To ensure a con- cylinders, or both.
sistent and predictable response to disasters, pre-deployment • Medications: pharmacy supplies for use on deployment need
to be stored in appropriate conditions. Medications such as
insulin, vaccinations, and most neuromuscular blocking
Table 2 Further resources agents require cold storage. The cold chain must be main-
tained during deployment. The preparation of medicines
EMT courses
should be considered. For example, thiopental and vecuro-
UK International http://uk-med.humanities.
nium are prepared in powdered form, giving the advantage
Emergency Trauma manchester.ac.uk
of being lightweight and having a long shelf life. A system
Register (UKIETR)
to ensure supplies are kept in date should be developed, for
Australian Medical http://www.nationaltraumacentre.
example, rotation of stock with a local hospital in the donor
Assistance Team Training nt.gov.au/what-we-do/disaster-
(AUSMAT) management/ausmat country between deployments.
New Zealand Medical https://www.health.govt.nz/our- • Blood availability: consideration of a living donor bank and a
Assistance Team Training work/new-zealand-medical- means of ABO typing and screening for infectious diseases.
(NZMAT) assistance-team • Food, water accommodation, waste, and sanitation: for staff,
Humanitarian Response http://hhi.harvard.edu/education/ patients, and patients families. For surgical procedures,
Intensive Course (USA) workshops/hric Médecins Sans Frontières (Doctors without Borders) guide-
Developing world anaesthesia courses lines recommend 100–300 litre water per patient per surgical
Developing World http://www.rcoa.ac.uk/education- procedure.18 A means of sterilizing and storing drinking
Anaesthesia Course (UK) and-events/developing-world- water should be pre-planned.
anaesthesia • Clothing: uniforms need to be climatically appropriate,
http://dwasouthwest.org protect staff from injury in the field, and facilitate easy identi-
Real World Anaesthesia https://www.asa.org.au fication of teams.
Course (Australia/ New
Zealand)
Global Outreach Course http://hhi.harvard.edu/education/ Disaster response and deployment
(Canada) workshops/hric
Response to an SOD should be co-ordinated at a national level.
Anaesthesia in Developing http://www.ndcn.ox.ac.uk/study/
The WHO-PAHO recommend that EMTs should be deployed
Countries (Uganda) continuing-professional-
development/anaesthesia-in- only after a declaration of emergency and invitation from the
developing-countries host country.7 National teams should be available to depart
with 12–24 h notice and be able to be deployed for at least 2–3

BJA Education | Volume 17, Number 1, 2017 25

Disaster management in a low-resource setting
weeks. Needs and expectations of the host country, local author-
ities, and local healthcare providers should be clearly defined.
On arrival in country, EMTs need to register with the host
country.2 7 19 The EMT must provide information on the level of
care they are able to provide, bed capacities (outpatient, in-
patient, surgical), team composition (number, specialities, level
of experience), time to deployment, estimated time to be oper-
ational, and logistics and support required. EMTs should agree
to adhere to the minimum set of professional and ethical stan-
dards, including carrying out only those procedures for which
they are accredited in their own country. A plan for collaboration
with local healthcare providers, local and national authorities,
and other EMTs should be agreed upon to improve complemen-
tarity of healthcare services. It is hoped that in the future, all EMT
provider organizations will be pre-registered on an international
database to allow better matching of supply and demand and
improved co-ordination, integration, standards, and time to
deployment.2 7 19 20
A clear exit strategy, hand-over process, and plans for follow
up and rehabilitation must be made in co-operation with the
host government and local healthcare providers.11 19 20
Anaesthesia in an FFH
Anaesthetists deployed as part of an EMT, when considering the
most appropriate type of anaesthetic, must be cognizant of the
specific issues raised when working in a resource-limited envir-
onment. Outside theatre, they will be call upon to manage acute
and chronic pain, assist trauma or neonatal resuscitation, and in
the evacuation or retrieval of patients where necessary.
Type of anaesthetic
Patient, environmental, equipment, and postoperative factors
will all influence the type of anaesthetic performed in an FFH.
Adequate oxygen supply by oxygen concentrator or cylinders, a
means of providing ventilation, suction, and for monitoring
oxygen saturation, arterial pressure, and end-tidal CO2 must be
available.
• Regional anaesthesia has been recognized as a beneficial
technique in developing countries and austere environments.
Spinal anaesthesia is simple, reasonably predictable, allows
the patient to breath spontaneously, provides good initial
postoperative analgesia, and has a relatively uncomplicated
recovery. It is useful for most procedures below the umbilicus.
Complex regional techniques such as peripheral nerve blocks
and nerve catheters have been described in situations such as
the care of the wounded combat soldier. In this situation, local
anaesthetic blocks and infusions allow for both intraoperative
anaesthesia and analgesia during the postoperative and re-
trieval phase. They may be useful in reducing the incidence
of persistent postoperative pain.21 22 The anaesthetist in an
FFH will need to consider the benefit of such a technique,
equipment availability, and the difference between war
zone injuries and those caused by disasters. Peripheral
nerve catheter-induced infections and complications are like-
ly to be low in injured soldiers who are able to be rapidly
removed from the battlefield and have a low incidence of co-
morbidities. Complications may be more likely in patients
with comorbidities such as diabetes with delayed presenta-
tions for management of wounds and secondary infections
caused by SODs.
• Inhalational anaesthesia: some presentations will be unsuit-
able for regional procedures. If inhalational anaesthesia is
to be provided, the anaesthetist must be familiar with the
26 BJA Education | Volume 17, Number 1, 2017
delivery device and understand any potential limitations.
For example, draw over vaporizers are robust, portable, and
do not rely on a pressurized gas supply. However, they are
wasteful of volatile agent, the presence of a self-inflating
bag makes spontaneous ventilation more difficult to observe,
and scavenging is cumbersome. Training in the use of draw-
over is required before deployment. Plenum machines with
circle circuits use less volatile agent. However, when com-
pared with drawover, they are generally expensive, fragile,
bulky, heavy, and require monitoring of inspired oxygen con-
centration and a means of absorbing carbon dioxide. A well-
regulated high-pressure gas supply is also needed.
• Total i.v. techniques: include propofol and ketamine-based
techniques, which can be used to provide sedation or general
anaesthesia. Benefits of a propofol-based general anaesthetic
include rapid wake up and recovery time, low rates of post-
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operative nausea and vomiting, and agent familiarity. Disad-
vantages include the need for additional analgesia and the
need for equipment such as infusion pumps with adequate
battery life or reliable power supply. Ketamine is well de-
scribed as a useful anaesthetic agent in low- and middle-in-
come countries. Its advantages include the provision of both
analgesia and anaesthesia, stable cardiovascular effects, and
relatively little respiratory depression. Disadvantages to be
considered in an FFH include a longer recovery phase and
the potential to induce hallucinations and delirium in
a patient who has recently experienced a traumatic event.
Combination i.v. techniques such as adding ketamine to
propofol (‘ketofol’) are documented.23 The ratio of dosage of
propofol and ketamine within these infusions must be con-
sidered with regard to supply of medication, analgesia, recov-
ery time, and number of recovery nursing staff.
Additional anaesthetic considerations
Other aspects to consider when performing anaesthesia in an
FFH include: availability of translators, appropriate preoperative
assessment, limited investigations, limited blood supply, con-
sent, documentation, antibiotic selection, management of com-
plications, postoperative analgesia, appropriate postoperative
care, and follow-up.
Ethical considerations
EMTs deploying from high-income countries are accustomed to
working in a resource-rich environment. They will face ethical di-
lemmas when arriving in a country with limited equipment, pa-
tient capacity, and treatment options. Ethical decisions will
include patient triage, which patients to accept for active treat-
ment and limits of patient care in an attempt to best utilize avail-
able resources such as operating theatres and ICU. During the
Haiti earthquake, the Israeli field hospital set up an ad hoc ethics
committee consisting of three senior clinicians not directly in-
volved in the care of the patient. The treating doctor presented
ethically challenging patients to the committee and was relieved
of the burden of determining the patients’ fate.24
Conclusion
Anaesthetists have a set of skills and attributes, meaning they
can be valuable members of an EMT responding to an inter-
national disaster. However, each individual has a responsibility
to ensure that they and their team have the appropriate training
and preparedness to work successfully in an austere environ-
ment. All teams need to be familiar with the recognized

minimum standards and to be prepared to work closely with
local teams to ensure effective care is provided.
Declaration of interest
Dr Phil Blum has provided volunteer anaesthetic services for the
Australian NCCTRC on international deployment.
MCQs
The associated MCQs (to support CME/CPD activity) can be
accessed at https://access.oxfordjournals.org by subscribers to
BJA Education.
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