Is Obstetrics and Gynecology Sonography Essential at a Field Hospital?
Is Obstetrics and Gynecology Sonography Essential at a Field Hospital Set up? Thoughts After the Earthquake - Turkey, 1999
David Mankuta MD, Adrian Rachstein MD , Yaron Bar-Dayan MD, Aharon
Finestone MD, Yoram Wolf MD, Maurizio Lynn MD, Paul Benedek MD, Arieh
Benedek MD, Arieh Eldad MD, Giora Martonovits MD
IDF Field Hospital Mission Team in Adapazari Turkey. IDF Medical
Corps.
Keywords: Earthquake, field hospital, Ultrasonography, pregnancy.
Address of correspondence: Dr. David Mankuta, Head of Obstetrics and
Gynecology, IDF Field Hospital, Adapazari, 2 Harduf Street, Lehavim,
Israel POB 162 Lehavim Zip 85338
Between day 4 and day 14 to the earthquake disaster in Turkey a field
hospital with an obstetric department was functioning in the city
Adapazari. The city obstetrics and gynecologic facilities were severely
compromised because of the earthquake and the field hospital had a major
role in this field in Adapazari. The role of an obstetric and gynecologic
sonography in a field hospital in a earthquake disaster is not discussed.
In this study we describe the main indications for field hospital
obstetric and gynecologic sonography and discuss the importance of this
tool in the context of a mass disaster with compromised local medical
facilities. A sonographic examination was done in 71 out of 123 obstetric
or gynecologic patients who were examined in the field hospital.
Biophysical score was the most common indication for the use of sonography in 36/71 (50.7%). Early pregnancy sonography was performed in 23 cases (18.6%) of all the patients. Although a vaginal probe was not provided we
estimate that it could add to the diagnosis in 29 case of all the Obstetric and Gynecologic patients seen. In 24 cases the sonographic
diagnosis eliminated the need for referral. One emergency case
referral
was by helicopter. Five others were referred by ambulance to a
tertiary
care. The sonographic test had significantly improved the emotional
status
of the patients.
Therefore, sonography at the level of the field serves to reduce the
number of required referrals, which are difficult in disaster
conditions
for the medical personnel and the patients. Although the cost of a
portable ultrasound is considerable, it seems that it's use for
diagnostic, and reassuring purposes is justified. Sonography might
also
play a role in reducing pregnant women's anxiety.
Introduction
A natural disaster has been defined as a disruption of human ecology
that exceeds the capacity of the community to function normally. On
August 17,
1999 at 03:04 am, an earthquake of 7.4 Richter scale struck the
Marmara
region, one of the most populated areas of Turkey. The estimated
number
of
casualties was 50,000, of them 20,000 fatalities and another 20,000
people
missing.
The earthquake significantly damaged the infrastructure of the cities
including that of the health system. Many local medical personnel and
facilities were either hurt, killed, or destroyed, respectively,
which
also made the remaining medical team ineffective. The Israeli defense
forces (IDF) have sent a field hospital to the affected area in order
to
assist and substitute for some of the hospital facilities and
services
that were significantly damaged in the earthquake. The IDF field
hospital
started to function from day 4 to day 14 after the earthquake in
the city
Adapazari - the second most severely damaged city in Turkey.
One of the departments of the field hospital was Obstetrics and
Gynecology. The services offered by the department were mostly
routine
primary and secondary care including operating facilities, which have
not
been functioning in the local medical facilities in the first
week after the earthquake.
Prior to the departure of the field hospital from Israel there were considerations regarding the role of an ultrasound in a setup of an earthquake. The aim of this study is to describe the role of an
ultrasound for Obstetrics in the field during a mass disaster and to recommend
about its use in a setup of a field hospital.
Methods
The Obstetrics and Gynecology facilities in Adapazari consisted of
three
fully equipped departments in three hospitals: Maternity and Neonatal
Care
Hospital, Social Security Hospital and State Hospital. The hospitals
have
provided Obstetrics and Gynecology services including,
Ultrasound, labor
room and operating facilities. Other primary care clinics as private
clinic were part of the health system in Adapazari.
The assignment of a IDF team was to provide primary, secondary and tertiary medical services to the region until the local facilities
will
recuperate and manage to provide medical care again. The field
hospital
offered a multi- disciplinary structure enabled a flexible mode of
operation and reduced the dependency of meticulous, time consuming
assessment of requirements prior to deployment. The Obstetrics and
Gynecology services provided a delivery suite, in and out patient
services
as well as ultrasound services.
The Ultrasound machine used was a portable Enraf Nonius Physioscan
100,
manufactured in Holland. The machine had two transducers: one of
Linear
3.5 MHz and the other a curvilinear 5 MHz. A trans-vaginal scan was
not
provided. The machine was encapsulated by bars in order to make it to
suitable for field purposes and reduce the chance of malfunction due
to
external trauma. The electricity for the machine was provided by a
220V
generator and did not depend on the local electricity that was cut
down
in
many parts of the city.
Results
The Obstetrics and Gynecology department started admitting patients
60 hours after the earthquake. At that stage the other medical
facilities
were almost paralyzed. 123 women were served at the Obstetrics and
Gynecology department out of a total of 1205 patients seen at the
hospital
all together. The average age of the women was 26 years. 77 patients
were
pregnant, the gestational ages ranged between 5 and 41.5 weeks.
18
patients were in the first trimester of the pregnancy, 17 in the
second
trimester and 42 in the 3rd trimester of pregnancy. A sonographic
examination was done in 71 patients. Biophysical score was the most
common
indication for the use of sonography in 36/71 (50.7%). Early
pregnancy
sonography was performed in 23 cases (18.6%) of all the patients.
Although
a vaginal probe was not provided we estimate that it could add to the
diagnosis in 29 case of all the Obstetric and Gynecologic patients
seen.
In 24 cases the sonographic diagnosis eliminated the need for
referral.
The referral targets were Istanbul or Ankara. Because many roads were
damaged during the earthquake the traveling time during referral was
between 4 to 10 hours. One emergency case referral was a helicopter.
Five
others were referred by ambulance to a tertiary care. A short
questionnaire was circulated among 15 pregnant patients, which were
about
to have a sonographic test to their pregnancies. 9 graded their
concerns
to be concerned up to extremely concerned in a scale of 1 to 5. After
the sonographic test ten of the fifteen patients said that they
would define
their current emotional status as calm up to anxious. Three patients
felt
extremely concerned even after the test.
Discussion
In the last several years the IDF has sent several delegations
worldwide
to areas of disasters causing mass casualties (1). In the first
delegations the medical equipment was based to the major task of the
team,
a military field hospital for trauma and non conventional weapon.
Gradually the equipment and medications were adjusted to the civilian requirement and an ultrasound machine was introduced due to the
possible
applications in Obstetrics and Gynecology as well as other medical
problems like abdominal trauma (2). The value of ultrasound as a
screening
tool was demonstrated in 12.8% of 400 patients of mass casualties,
screened after the Armenian earthquake in 1988. To the best of our
knowledge, this is the first report of use of Obstetrical and
Gynecologic
sonography in such a field hospital setup.
Mass disaster such as an
earthquake may have adverse effects on reproductive outcome. Many
women
believe it may affect their pregnancy although usually they do not
base
their belief on scientific studies. Lately there have been several
studies
suggesting correlation between mass casualties and adverse
reproductive
outcomes and infertility, early pregnancy loss, stillbirths and
serious
developmental disabilities such as cerebral palsy and mental
retardation (3,4). On the 2nd of March 1985, 8-9 Richter scale earthquake and a
series
of aftershocks took place in Santiago, Chile. The characteristics of
over
22,000 births registered in three public hospitals in the same
year were
reviewed. A significant increase in the rate of facial clefts was
found.
2.01 per 1000 births in contrast to 1.6 per 1000 births in previous
years.
The increase was greater in those born in September: 3.8 per 1000
births.
This increase in clefting could be related to the effects of
stress in
mothers induced by the earthquake. The authors have applied and to
test
this hypothesis 13.5-day-old embryos from two inbred mouse strains,
A/Sn
and C57BL/10, were subjected to a similar stress using a vibrator
cage to
imitate the main shock and the first five replicas of the
earthquake. The
same intensity and duration of shock as in the original
earthquake were
applied. The results were 19.8% cleft palates in stressed A/Sn mice
and
no
clefting in C57BL/10. These findings in mice support the stress
hypothesis
for the increase in cleft palate observed in humans. The increase in
resorbed embryos in both strains also suggests an effect on stress.
Sonography has been shown to be a technology that may reassure
expecting
mothers on one hand while alarming others depending on the clinical
setup.
Based on our limited data on mother's concerns about their
pregnancies following this mass disaster it seems that sonographic testing of the
pregnancies, showing the mothers the screen including fetal heart
beats
has some reassuring role as well as a diagnostic test for better care
of
pregnant women during mass casualties.
In conclusion, The indications and extent of sonographic use for
obstetrics and gynecology in a field hospital during an earthquake
disaster are described for the first time. The evaluation of fetal
biophysical score is the most common indication for the test.
Sonography
at the level of the field serves to reduce the number of required
referrals, which are difficult in disaster conditions for the medical personnel and the patients. Although the cost of a portable
ultrasound is
considerable, it seems that it's use for diagnostic, and
reassuring
purposes is justified. The women's common belief that severe anxiety
may
affect the reproductive outcome is supported by some clinical as well
as
animal studies. Sonography might also play a role in reducing the
pregnant
women's anxiety.
References
1. Heyman SN, Eldad A and Wiener M, Airborne field hospital in
disaster area: lessons from Armenia (1988) and Rwanda (1994). Prehospital
Disaster
Med, 1998; 13: 21-28.
2. Sarkisian AE, Khondkarian RA, Amirbekian NM, Bagdasarian NB,
Khojayan RI and Oganesian YT, Sonographic screening of mass casualties for
abdominal and renal injuries following the 1988 Armenian earthquake.
J
Trauma 1991;31: 247-250.
3. Cordero JF, The epidemiology of disasters and adverse reproductive
outcomes: lessons learned. Environ Health Perspect, 1993; 101: 131-6.
4. Montenegro MA, Palomino H, Palomino HM. The influence of
earthquake-
induced stress on human facial clefting and its simulation
in mice.
Arch Oral Biol 1995; 40: 33-7.
Table 1: The distribution of indications for sonography in the IDF
field hospital in Adapazari.
___________________________________________________________
Indication for sonography Number (%) of
patients
___________________________________________________________
Biophysical score 27 (38%)
Biophysical and biometry 9 (12.7%)
Fetal heart rate and CRL 23 (32.4%)
Pelvic structures 6 (8.5%)
Fetal heart rate only 4 (5.6%)
Placental site and pathology 2 (2.8%)
Total 71 (100%)
__________________________________________________________
Competing interests:
___________________________________________________________Indication for sonography Number (%) of patients ___________________________________________________________Biophysical score 27 (38%) Biophysical and biometry 9 (12.7%)Fetal heart rate and CRL 23 (32.4%)Pelvic structures 6 (8.5%)Fetal heart rate only 4 (5.6%)Placental site and pathology 2 (2.8%)Total 71 (100%)__________________________________________________________
13 September 1999
D Mankuta
IDF Field Hospital Mission Team
A Rachstein, Y Bar-Dayan, A Finestone, Y Wolf, M Lynn, P Benedek, A Eldad, G Martonovits
Rapid Response:
Is Obstetrics and Gynecology Sonography Essential at a Field Hospital?
Is Obstetrics and Gynecology Sonography Essential at a Field Hospital Set up? Thoughts After the Earthquake - Turkey, 1999
David Mankuta MD, Adrian Rachstein MD , Yaron Bar-Dayan MD, Aharon
Finestone MD, Yoram Wolf MD, Maurizio Lynn MD, Paul Benedek MD, Arieh
Benedek MD, Arieh Eldad MD, Giora Martonovits MD
IDF Field Hospital Mission Team in Adapazari Turkey. IDF Medical
Corps.
Keywords: Earthquake, field hospital, Ultrasonography, pregnancy.
Address of correspondence: Dr. David Mankuta, Head of Obstetrics and
Gynecology, IDF Field Hospital, Adapazari, 2 Harduf Street, Lehavim,
Israel POB 162 Lehavim Zip 85338
Phone/Fax: 972-7-6510093
E-mail: mankuta@excite.com
Abstract
Between day 4 and day 14 to the earthquake disaster in Turkey a field
hospital with an obstetric department was functioning in the city
Adapazari. The city obstetrics and gynecologic facilities were severely
compromised because of the earthquake and the field hospital had a major
role in this field in Adapazari. The role of an obstetric and gynecologic
sonography in a field hospital in a earthquake disaster is not discussed.
In this study we describe the main indications for field hospital
obstetric and gynecologic sonography and discuss the importance of this
tool in the context of a mass disaster with compromised local medical
facilities. A sonographic examination was done in 71 out of 123 obstetric
or gynecologic patients who were examined in the field hospital.
Biophysical score was the most common indication for the use of sonography in 36/71 (50.7%). Early pregnancy sonography was performed in 23 cases (18.6%) of all the patients. Although a vaginal probe was not provided we
estimate that it could add to the diagnosis in 29 case of all the Obstetric and Gynecologic patients seen. In 24 cases the sonographic
diagnosis eliminated the need for referral. One emergency case
referral
was by helicopter. Five others were referred by ambulance to a
tertiary
care. The sonographic test had significantly improved the emotional
status
of the patients.
Therefore, sonography at the level of the field serves to reduce the
number of required referrals, which are difficult in disaster
conditions
for the medical personnel and the patients. Although the cost of a
portable ultrasound is considerable, it seems that it's use for
diagnostic, and reassuring purposes is justified. Sonography might
also
play a role in reducing pregnant women's anxiety.
Introduction
A natural disaster has been defined as a disruption of human ecology
that exceeds the capacity of the community to function normally. On
August 17,
1999 at 03:04 am, an earthquake of 7.4 Richter scale struck the
Marmara
region, one of the most populated areas of Turkey. The estimated
number
of
casualties was 50,000, of them 20,000 fatalities and another 20,000
people
missing.
The earthquake significantly damaged the infrastructure of the cities
including that of the health system. Many local medical personnel and
facilities were either hurt, killed, or destroyed, respectively,
which
also made the remaining medical team ineffective. The Israeli defense
forces (IDF) have sent a field hospital to the affected area in order
to
assist and substitute for some of the hospital facilities and
services
that were significantly damaged in the earthquake. The IDF field
hospital
started to function from day 4 to day 14 after the earthquake in
the city
Adapazari - the second most severely damaged city in Turkey.
One of the departments of the field hospital was Obstetrics and
Gynecology. The services offered by the department were mostly
routine
primary and secondary care including operating facilities, which have
not
been functioning in the local medical facilities in the first
week after the earthquake.
Prior to the departure of the field hospital from Israel there were considerations regarding the role of an ultrasound in a setup of an earthquake. The aim of this study is to describe the role of an
ultrasound for Obstetrics in the field during a mass disaster and to recommend
about its use in a setup of a field hospital.
Methods
The Obstetrics and Gynecology facilities in Adapazari consisted of
three
fully equipped departments in three hospitals: Maternity and Neonatal
Care
Hospital, Social Security Hospital and State Hospital. The hospitals
have
provided Obstetrics and Gynecology services including,
Ultrasound, labor
room and operating facilities. Other primary care clinics as private
clinic were part of the health system in Adapazari.
The assignment of a IDF team was to provide primary, secondary and tertiary medical services to the region until the local facilities
will
recuperate and manage to provide medical care again. The field
hospital
offered a multi- disciplinary structure enabled a flexible mode of
operation and reduced the dependency of meticulous, time consuming
assessment of requirements prior to deployment. The Obstetrics and
Gynecology services provided a delivery suite, in and out patient
services
as well as ultrasound services.
The Ultrasound machine used was a portable Enraf Nonius Physioscan
100,
manufactured in Holland. The machine had two transducers: one of
Linear
3.5 MHz and the other a curvilinear 5 MHz. A trans-vaginal scan was
not
provided. The machine was encapsulated by bars in order to make it to
suitable for field purposes and reduce the chance of malfunction due
to
external trauma. The electricity for the machine was provided by a
220V
generator and did not depend on the local electricity that was cut
down
in
many parts of the city.
Results
The Obstetrics and Gynecology department started admitting patients
60 hours after the earthquake. At that stage the other medical
facilities
were almost paralyzed. 123 women were served at the Obstetrics and
Gynecology department out of a total of 1205 patients seen at the
hospital
all together. The average age of the women was 26 years. 77 patients
were
pregnant, the gestational ages ranged between 5 and 41.5 weeks.
18
patients were in the first trimester of the pregnancy, 17 in the
second
trimester and 42 in the 3rd trimester of pregnancy. A sonographic
examination was done in 71 patients. Biophysical score was the most
common
indication for the use of sonography in 36/71 (50.7%). Early
pregnancy
sonography was performed in 23 cases (18.6%) of all the patients.
Although
a vaginal probe was not provided we estimate that it could add to the
diagnosis in 29 case of all the Obstetric and Gynecologic patients
seen.
In 24 cases the sonographic diagnosis eliminated the need for
referral.
The referral targets were Istanbul or Ankara. Because many roads were
damaged during the earthquake the traveling time during referral was
between 4 to 10 hours. One emergency case referral was a helicopter.
Five
others were referred by ambulance to a tertiary care. A short
questionnaire was circulated among 15 pregnant patients, which were
about
to have a sonographic test to their pregnancies. 9 graded their
concerns
to be concerned up to extremely concerned in a scale of 1 to 5. After
the sonographic test ten of the fifteen patients said that they
would define
their current emotional status as calm up to anxious. Three patients
felt
extremely concerned even after the test.
Discussion
In the last several years the IDF has sent several delegations
worldwide
to areas of disasters causing mass casualties (1). In the first
delegations the medical equipment was based to the major task of the
team,
a military field hospital for trauma and non conventional weapon.
Gradually the equipment and medications were adjusted to the civilian requirement and an ultrasound machine was introduced due to the
possible
applications in Obstetrics and Gynecology as well as other medical
problems like abdominal trauma (2). The value of ultrasound as a
screening
tool was demonstrated in 12.8% of 400 patients of mass casualties,
screened after the Armenian earthquake in 1988. To the best of our
knowledge, this is the first report of use of Obstetrical and
Gynecologic
sonography in such a field hospital setup.
Mass disaster such as an
earthquake may have adverse effects on reproductive outcome. Many
women
believe it may affect their pregnancy although usually they do not
base
their belief on scientific studies. Lately there have been several
studies
suggesting correlation between mass casualties and adverse
reproductive
outcomes and infertility, early pregnancy loss, stillbirths and
serious
developmental disabilities such as cerebral palsy and mental
retardation (3,4). On the 2nd of March 1985, 8-9 Richter scale earthquake and a
series
of aftershocks took place in Santiago, Chile. The characteristics of
over
22,000 births registered in three public hospitals in the same
year were
reviewed. A significant increase in the rate of facial clefts was
found.
2.01 per 1000 births in contrast to 1.6 per 1000 births in previous
years.
The increase was greater in those born in September: 3.8 per 1000
births.
This increase in clefting could be related to the effects of
stress in
mothers induced by the earthquake. The authors have applied and to
test
this hypothesis 13.5-day-old embryos from two inbred mouse strains,
A/Sn
and C57BL/10, were subjected to a similar stress using a vibrator
cage to
imitate the main shock and the first five replicas of the
earthquake. The
same intensity and duration of shock as in the original
earthquake were
applied. The results were 19.8% cleft palates in stressed A/Sn mice
and
no
clefting in C57BL/10. These findings in mice support the stress
hypothesis
for the increase in cleft palate observed in humans. The increase in
resorbed embryos in both strains also suggests an effect on stress.
Sonography has been shown to be a technology that may reassure
expecting
mothers on one hand while alarming others depending on the clinical
setup.
Based on our limited data on mother's concerns about their
pregnancies following this mass disaster it seems that sonographic testing of the
pregnancies, showing the mothers the screen including fetal heart
beats
has some reassuring role as well as a diagnostic test for better care
of
pregnant women during mass casualties.
In conclusion, The indications and extent of sonographic use for
obstetrics and gynecology in a field hospital during an earthquake
disaster are described for the first time. The evaluation of fetal
biophysical score is the most common indication for the test.
Sonography
at the level of the field serves to reduce the number of required
referrals, which are difficult in disaster conditions for the medical personnel and the patients. Although the cost of a portable
ultrasound is
considerable, it seems that it's use for diagnostic, and
reassuring
purposes is justified. The women's common belief that severe anxiety
may
affect the reproductive outcome is supported by some clinical as well
as
animal studies. Sonography might also play a role in reducing the
pregnant
women's anxiety.
References
1. Heyman SN, Eldad A and Wiener M, Airborne field hospital in
disaster area: lessons from Armenia (1988) and Rwanda (1994). Prehospital
Disaster
Med, 1998; 13: 21-28.
2. Sarkisian AE, Khondkarian RA, Amirbekian NM, Bagdasarian NB,
Khojayan RI and Oganesian YT, Sonographic screening of mass casualties for
abdominal and renal injuries following the 1988 Armenian earthquake.
J
Trauma 1991;31: 247-250.
3. Cordero JF, The epidemiology of disasters and adverse reproductive
outcomes: lessons learned. Environ Health Perspect, 1993; 101: 131-6.
4. Montenegro MA, Palomino H, Palomino HM. The influence of
earthquake-
induced stress on human facial clefting and its simulation
in mice.
Arch Oral Biol 1995; 40: 33-7.
Table 1: The distribution of indications for sonography in the IDF
field hospital in Adapazari.
___________________________________________________________ Indication for sonography Number (%) of patients ___________________________________________________________ Biophysical score 27 (38%) Biophysical and biometry 9 (12.7%) Fetal heart rate and CRL 23 (32.4%) Pelvic structures 6 (8.5%) Fetal heart rate only 4 (5.6%) Placental site and pathology 2 (2.8%) Total 71 (100%) __________________________________________________________Competing interests: ___________________________________________________________Indication for sonography Number (%) of patients ___________________________________________________________Biophysical score 27 (38%) Biophysical and biometry 9 (12.7%)Fetal heart rate and CRL 23 (32.4%)Pelvic structures 6 (8.5%)Fetal heart rate only 4 (5.6%)Placental site and pathology 2 (2.8%)Total 71 (100%)__________________________________________________________