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Lord S, Lee J. Critical Care in the Austere Environment. Crit Care Clin 2024; 40:451-462. [PMID: 38796220 DOI: 10.1016/j.ccc.2024.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2024]
Abstract
Practice of critical care in austere settings involves navigating rapidly evolving environments, where physical resources, provider availability, and healthcare capacity are constrained. Austere Critical Care focuses on maintaining the highest standard of care possible for patients while also identifying resource limitations, responding to patient surges, and adhering to proper triage practices at the austere site. This includes transferring the patient when able and necessary. This article describes the current practice of critical care medicine in the austere environment, using recent natural disasters, pandemics, and conflicts as case studies.
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Affiliation(s)
- Spencer Lord
- Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, USA.
| | - Jarone Lee
- Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, USA
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Frechette R, Colas N, Augustin M, Edema N, Pyram G, Louis S, Crevecoeur CE, Mathurin C, Louigne R, Patel B, Humphreys M, Chapital A, Martin M, Ayoub Q, Hottinger D, McCurdy MT, Tran Q, Skupski R, Zimmer D, Walsh M. Sustainable surgical resource initiative for Haiti: the SSRI-Haiti project. Glob Health Action 2023; 16:2180867. [PMID: 36856725 PMCID: PMC9980030 DOI: 10.1080/16549716.2023.2180867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023] Open
Abstract
In response to the 2010 earthquake and subsequent cholera epidemic, St Luke's Medical Center was established in Port-au-Prince, Haiti. Here, we describe its inception and evolution to include an intensive care unit and two operating rooms, as well as the staffing, training and experiential learning activities, which helped St Luke's become a sustainable surgical resource. We describe a three-phase model for establishing a sustainable surgical centre in Haiti (build facility and acquire equipment; train staff and perform surgeries; provide continued education and expansion including regular specialist trips) and we report a progressive increase in the number and complexity of cases performed by all-Haitian staff from 2012 to 2022. The results are generalised in the context of the 'delay framework' to global health along with a discussion of the application of this three-phase model to resource-limited environments. We conclude with a brief description of the formation of a remote surgical centre in Port-Salut, an unforeseen benefit of local competence and independence. Establishing sustainable and collaborative surgery centres operated by local staff accelerates the ability of resource-limited countries to meet high surgical burdens.
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Affiliation(s)
- Richard Frechette
- Departments of Critical Care Medicine and Surgery, Saint Luke's Medical Center, Port-au-Prince, Haiti
| | - Nathalie Colas
- Departments of Critical Care Medicine and Surgery, Saint Luke's Medical Center, Port-au-Prince, Haiti
| | - Marc Augustin
- Departments of Critical Care Medicine and Surgery, Saint Luke's Medical Center, Port-au-Prince, Haiti
| | - Nathalie Edema
- Departments of Critical Care Medicine and Surgery, Saint Luke's Medical Center, Port-au-Prince, Haiti
| | - Gerson Pyram
- Departments of Critical Care Medicine and Surgery, Saint Luke's Medical Center, Port-au-Prince, Haiti
| | - Stanley Louis
- Departments of Critical Care Medicine and Surgery, Saint Luke's Medical Center, Port-au-Prince, Haiti
| | - Carl Eric Crevecoeur
- Departments of Critical Care Medicine and Surgery, Saint Luke's Medical Center, Port-au-Prince, Haiti
| | - Carmeline Mathurin
- Departments of Critical Care Medicine and Surgery, Saint Luke's Medical Center, Port-au-Prince, Haiti
| | - Raphael Louigne
- Departments of Critical Care Medicine and Surgery, Saint Luke's Medical Center, Port-au-Prince, Haiti
| | - Bhavesh Patel
- Departments of Critical Care Medicine, Urology and Surgery, Mayo Clinic and Global, Surgical, Destination, Healthcare Inc., Phoenix, AZ, USA
| | - Mitchell Humphreys
- Departments of Critical Care Medicine, Urology and Surgery, Mayo Clinic and Global, Surgical, Destination, Healthcare Inc., Phoenix, AZ, USA
| | - Alyssa Chapital
- Departments of Critical Care Medicine, Urology and Surgery, Mayo Clinic and Global, Surgical, Destination, Healthcare Inc., Phoenix, AZ, USA
| | - Mallory Martin
- Departments of Critical Care Medicine and Surgery, Saint Luke's Medical Center, Port-au-Prince, Haiti
| | - Qamarissa Ayoub
- Bamiyan Maternal and Child Health Project and the Andeshgah Library, Kabul, Afghanistan
| | - Daniel Hottinger
- Department of Anesthesia, Metropolitan Anesthesia Network, LLP, Plymouth, MN, USA
| | - Michael T McCurdy
- Division of Pulmonary & Critical Care Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Quincy Tran
- Division of Pulmonary & Critical Care Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Richard Skupski
- Department of Medical Education, University of Indiana School of Medicine, South Bend/Notre Dame Campus, South Bend, IN, USA.,Department of Anesthesia, Memorial Hospital Beacon Medical Group of South Bend, South Bend, IN, USA
| | - Donald Zimmer
- Department of Medical Education, University of Indiana School of Medicine, South Bend/Notre Dame Campus, South Bend, IN, USA.,Department of Emergency Medicine, Memorial Hospital Beacon Medical Group of South Bend, South Bend, IN, USA
| | - Mark Walsh
- Department of Medical Education, University of Indiana School of Medicine, South Bend/Notre Dame Campus, South Bend, IN, USA.,Departments of Emergency and Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN, USA
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The Next Frontier in Neurocritical Care in Resource-Constrained Settings. Crit Care Clin 2022; 38:721-745. [PMID: 36162907 DOI: 10.1016/j.ccc.2022.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Neurocritical care (NCC) is an emerging field within critical care medicine, reflecting the widespread prevalence of neurologic injury in critically ill patients. Morbidity and mortality from neurocritical illness (NCI) have been reduced substantially in resource-rich settings (RRS), owing to the development of advanced technologies, neuro-specific units, and subspecialized medical training. Despite shouldering much of the burden of NCI worldwide, resource-limited settings (RLS) face immense hurdles when implementing guidelines generated in RRS. This review summarizes the current epidemiology, management, and outcomes of the most common NCIs in RLS and offers commentary on future directions in NCC practiced in RLS.
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Vande Lune SA, Lantry JH, Mason PE, Skupski R, Toth A, Zimmer D, Mulligan J, McCurdy MT, Larson EE, Preuss F, Tran QK. Universal Anesthesia Machine: Clinical Application in an Austere, Resource-Limited Environment. Mil Med 2021; 185:e550-e556. [PMID: 31889189 DOI: 10.1093/milmed/usz438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 07/27/2019] [Accepted: 11/06/2019] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION In austere environments, the safe administration of anesthesia becomes challenging because of unreliable electrical sources, limited amounts of compressed gas, and insufficient machine maintenance capabilities. Such austere environments exist in battlefield medicine, in low- and middle-income countries (LMICs), and in areas struck by natural disasters. Whether in military operations or civilian settings, the Universal Anesthesia Machine (UAM) (Gradian Health Systems, New York, New York) is a draw-over device capable of providing safe and effective general anesthesia when external oxygen supplies or reliable electrical sources are limited. This brief report discusses a proof-of-concept observational study demonstrating the clinical utility of the UAM in a resource-limited area. MATERIALS AND METHODS This observational study of 20 patients in Haiti who underwent general anesthesia using the UAM highlights the device's capability to deliver anesthesia intraoperatively in a resource-limited LMIC clinical setting. Preoxygenation was achieved with the UAM's draw-over oxygen supply. Patients received acetaminophen for analgesia, dexmedetomidine for preinduction anesthesia, and succinylcholine for paralysis. After induction, the UAM provided a mixture of oxygen and isoflurane for maintenance of anesthesia. Manual ventilation was performed using draw-over bellows until spontaneous ventilation recurred, when clinically appropriate, artificial airways were removed. Intraoperative medication was administered at the anesthesiologist's discretion. The institutional review board at the U.S. anesthesiologists' affiliated institution and the Haitian hospital approved this study; patients were consented in their native language. RESULTS Two anesthesiologists used the UAM to deliver general anesthesia to 20 patients in a Haitian hospital without access to an external oxygen supply, reliable power grid, or opioids. The patients' average age was ~40 years, and 90% of them were male. Most of the cases were herniorrhaphy (50%) and hydrocelectomy (25%) surgeries. The median American Society of Anesthesiologists (ASA) score was 2; 45% of the patients had an ASA score of 1, and none had an ASA score >3. Of the 20 cases, 55% of patients received an endotracheal tube, and 40% received a laryngeal mask airway; for one patient, only a masked airway was used. Every patient was discharged on the day of the surgery. No complications occurred in the perioperative or 1-month follow-up period. CONCLUSION The UAM can be used where a lack of resources and training exist because of its simple design, built-in oxygen concentrator, and capacity to revert from continuous-flow to draw-over anesthesia in the event of a power failure or if external oxygen supplies are unavailable. We believe the UAM addresses some of the shortcomings of modern anesthesia machines and has the potential to improve the delivery of safe general anesthesia in combat and austere scenarios. Further studies could consider different types of surgeries than those reported here and involve more complex patients. Studies involving alternative anesthetic agents and non-anesthesiologist personnel are also needed. Overall, this brief report detailing the use of the UAM following a natural disaster in a LMIC is proof of concept that the machine can provide reliable anesthesia for surgical procedures in austere and resource-limited environments, including disaster areas and modern combat zones.
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Affiliation(s)
- Stefani A Vande Lune
- Indiana University School of Medicine-South Bend, 1044 E. Angela Blvd, South Bend, IN 46617
| | - James H Lantry
- Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814.,Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, 110 S. Paca Street, 2nd Floor, Baltimore, MD 21201
| | - Phillip E Mason
- San Antonio Military Medical Center, 21 Spurs Lane, San Antonio, TX 78240
| | - Richard Skupski
- Indiana University School of Medicine-South Bend, 1044 E. Angela Blvd, South Bend, IN 46617.,Memorial Hospital, 615 N. Michigan Street, South Bend, IN 46601
| | - Arthur Toth
- Memorial Hospital, 615 N. Michigan Street, South Bend, IN 46601
| | - Donald Zimmer
- Memorial Hospital, 615 N. Michigan Street, South Bend, IN 46601
| | - John Mulligan
- Chandler Regional Medical Center, 1955 W. Frye Road, Chandler, AZ 85224.,Mercy Gilbert Medical Center, 3555 S. Val Vista Drive, Gilbert, AZ 85297
| | - Michael T McCurdy
- Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, 110 S. Paca Street, 2nd Floor, Baltimore, MD 21201
| | - Emilee E Larson
- Indiana University School of Medicine-South Bend, 1044 E. Angela Blvd, South Bend, IN 46617
| | - Fletcher Preuss
- University of Virginia School of Medicine, 1215 Lee Street, Charlottesville, VA 22908
| | - Quincy K Tran
- Department of Emergency Medicine, University of Maryland School of Medicine, 22 S. Greene Street, Baltimore, MD 21021.,The R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, 22 S. Greene Street, Baltimore, MD 21201
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