Trauma Management in the Jungle

In 1998, Tom Lee accompanied Planet Care founder Ben Brown on a trip to the Thai-Burma border. Impressed by the work of Planet Care to support Burmese people living in Thailand, Tom looked across the border to the needs of the internally displaced communities living without healthcare inside Burma. Soon, after, he founded Global Health Access Program (GHAP) along with Anusha Dahanayake, Heather Kuiper and Loren Rauch to fill in the health care, program, and policy gaps that contribute to Burma's health crisis. Larry Stock, Allison Richard and her ER doctor husband Matthew Richard joined them.

Stories and pictures of what GHAP does can be seen on the small organization's website: www.GHAP.org. In a video, a PowerPoint presentation, and printed handouts (copies of the article "Essential trauma management training: addressing service delivery needs in active: conflict zones in eastern Myanmar" from the March 3, 2009 issue of Human Resources for Health [available at http://www.human-resources-health.com/content/7/1/19] and "BackPack doctors risk Burma's wrath" appearing in the March 22, 2009 San Francisco Chronicle which is available at www.sfgate.com) Larry defined the problem and what the GHAP organization does. Much of the information below comes from the Human Resources for Health article.

The government of Myanmar directs less than 3% of its budget annually towards health care, resulting in scant services for its people. In the border regions, access to both governmental and international nongovernmental sources of health care is worse than the rest of the country. This is largely a result of civil conflict and governmental restrictions that have persisted for decades. While much of the attention is rightfully paid to the problem of infectious diseases and a failing health care system in Myanmar, attention must also be paid to the widespread use of landmines. The 2007 Landmine monitor report indentifies Myanmar as one of the few countries experiencing in increase in the number of landmine casualty rates in 2006, reporting 243 new casualties, up from 231 in 2005. These statistics, however, likely reflect severe underreporting, as most injuries occur in areas where data are not routinely collected.

Mortality surveys conducted in an eastern Myanmar conflict zone in 2002 demonstrated that 4% of all deaths were attributable to landmines. The casualties are usually civilians of all ages. The Karen Human Rights Group has documented villagers' reports of "atrocity demining," whereby the Myanmar Army forces villagers to walk in front of soldiers as human minesweepers. In addition the Thailand Burma Border Consortium stated that mines are often placed near rice fields to prevent villagers from cultivating the land and to aid in the displacement of these civilian populations. A survey of human rights violations in eastern Myanmar found that households that were forcibly displaced were four times more likely to have a household member become a landmine victim.

For the significant proportion of adults and children who survive the initial blast, rapid access to care is crucial. Beyond initial stabilization, higher-level care is essential, as many survivors require critical actions, including amputation. The Myanmar government's so-called "Four Cuts Policy," which aims to cut off the supply of food, funding, information and recruits to ethnic minority insurgents, also prevents access to government and international forms of humanitarian assistance. By 2004 there were more than 500,000 internally displaced persons (IDPs) in eastern Myanmar, living in areas with virtually no access to hospitals, physicians or nurses.

In response to these needs, community-based organizations (CBOs) have mobilized to address the most pressing health problems. Two organizations involved in trauma care in eastern Myanmar are the Karen Department of Health and Welfare (KDHW), and the Backpack Health Worker Teams (BPHWT). KDHW is the health department of the Karen National Union, the Karen State (Eastern Myanmar) government-in-exile of the ethnic Karen people. KDHW manages 33 mobile clinics providing care for more than 100 000 internally displaced persons (IDPs) and war-affected residents of Karen State. The clinics are mobile in the sense that they are based in bamboo structures and can be moved quickly in case of attack. Five to ten health workers staff each clinic. BPHWT formed in 1998 to deliver health care services to the most remote areas within the conflict zones of eastern Myanmar. BPHWT is a multiethnic organization (Karen, Karenni, Mon and Shan) that has 90 teams of three to five health workers per team providing care for more than 150 000 IDPs. These mobile teams serve more unstable areas, where it would be impossible to have even semipermanent clinics.

The 711 KDHW and BPHWT health workers are a diverse group. They range in age from 19 to 55 years, 54% male and 46% female. They have received training from a variety of sources including KDHW, BPHWT, IDP camps in Myanmar, refugee camps in Thailand and Mao Tao Clinic (MTC). MTC was established in 1988 by Dr Cynthia Maung in Mae Sot, Thailand, and is the largest training and treatment centre for exiles who have fled to Thailand from Myanmar, yet who are not living under refugee status. Training for a health worker ranges from 4 to 18 months and includes intensive training in basic primary care, infectious disease, maternal child care, first aid and public health. A subset of these health workers returns to the Thai border every six months to receive further training, to exchange data and to resupply.

Beginning in 2000, a four-to-six-day trauma course for health workers was established by the Global Health Access Program (GHAP) in conjunction with KDHW to teach basic competences in caring for trauma victims. Class composition of approximately 30 students has been two thirds health workers without prior trauma training and one third with prior training and experience in trauma management. KDHW leaders have selected student participants with the goal of creating integrated trauma teams of experienced and less-experienced health workers.

Course instructors have included GHAP and AAI volunteer physicians, registered nurses, nurse practitioners and pre-hospital care personnel, together with the more experienced trauma health workers. Volunteer physicians have included emergency medicine physicians, general surgeons and orthopaedic surgeons. A training-of-trainers program is embedded in the current course, in which the experienced trauma health workers serve as mentors, small group leaders and lecturers during the biannual course, thus increasing their capacity as trainers within their health care system. The curriculum covers the evaluation and management of the trauma victim, with an emphasis on resuscitation, stabilization, recognition and management of shock, wound care and prevention of infection, sepsis and organ failure.

The trauma course content has drawn from resources developed by the TCF, the International Committee of the Red Cross, Dr Maurice King's series of books on primary surgical care and a variety of other authoritative sources. The course focuses on the early and aggressive management of limb injuries, including control of bleeding, wound care, fasciotomy, amputation, fracture and dislocation management, splinting and casting. Other skills taught include: suturing; anaesthesia and analgesia; preoperative, operative and postoperative care; monitoring, hygiene and psychological care of the trauma patient; rehabilitation; basic and advanced/surgical airway; tube thoracostomy; venous cut down; nasogastric and urine catheter use; intravenous fluid therapy; blood typing; and blood transfusion. A short, focused lecture followed by a clinical activity has been the typical teaching pattern, within a three-hour teaching block each morning and each afternoon. Activities include role-playing, skills labs and case reviews. The TMP provides trauma teams with a standard set of supplies, including stethoscopes, surgical instruments, headlamps, files, amputation saws and modified tourniquets. Other basic supplies include gloves; gauze; ace wraps; tape; suture; tubing for airways and chest tubes; irrigation supplies; injection and IV supplies; rapid diagnostic kits for HIV and blood typing; blood transfusion supplies; and antiseptics. Medications include basic oral and IV antibiotics, analgesics and anaesthetics.

The Human Resources for Health article evaluated the success of the program in saving life and limb in the treacherous environment the displaced Burmese find themselves in. The TMP has created data collection tools to facilitate the process of patient care, resource management and trauma patient outcomes analysis. Data collection began in June 2005. Health workers complete each form in the field while they are conducting patient care. Data fields include patient name; age; sex; date and time of injury; mechanism of injury; region of body injured; date and time of health worker arrival to patient and departure from patient; treatment given; referral information; and survival information. Trauma health workers are not activated for deceased victims; any patient who died prior to health worker arrival is excluded from the Trauma Care Registry.

A wide variety of trauma mechanisms were reported, including weapons-related, accident and animal attack. The majority (72%), however, were a result of weapons-related trauma. Landmine injury was the most common type, followed by gunshot wounds. A few additional cases of stab and mortar/RPG injury were reported. Of all patients receiving care by the health workers, the vast majority (91%) survived and were alive at the time of last contact. This is indeed an amazing statistic given the circumstances of these injuries, their remote jungle location, and the limited training of the care givers. Larry pointed out that these volunteer health care workers from Burma were doing amazing medical work even before the GHAP doctors arrived on the scene. The GHAP try to teach them the proper techniques, and try to give them medical supplies and equipment that can be used in the jungle environment. The volunteers of GHAP pay their way to give the service they give. They operate on a shoestring budget.

One of the reasons for Larry's presentation is to see how Rotary can help. We recommended that Larry get in contact with Rotary clubs in Burma to see if there is a possibility for Rotary Foundation grant. He would also like to speak to local Rotary clubs interested in this project.