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PECIAL COMMUNICATION

pinal Cord Injury Management and Rehabilitation: Highlightsnd Shortcomings From the 2005 Earthquake in Pakistanarooq A. Rathore, MBBS, Fareeha Farooq, MBBS, Sohail Muzammil, MBBS, FRCS,

eter W. New, M Clin Epi, Nadeem Ahmad, MBBS, FRCS, Andrew J. Haig, MD

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ABSTRACT. Rathore FA, Farooq F, Muzammil S, NewW, Ahmad N, Haig AJ. Spinal cord injury management andehabilitation: highlights and shortcomings from the 2005arthquake in Pakistan. Arch Phys Med Rehabil 2008;89:79-85.

Recent natural disasters have highlighted the lack of plan-ing for rehabilitation and disability management in emergen-ies. A review of our experience with spinal cord injury (SCI)fter the Pakistan earthquake of 2005, plus a review of otheriterature about SCI after natural disasters, shows that largeumbers of people will incur SCIs in such disasters. Thepidemiology of SCI after earthquakes has not been well stud-ed and may vary with location, severity of the disaster, avail-ble resources, the expertise of the health care providers, andultural issues. A lack of preparedness means that evacuationrotocols, clinician training, dedicated acute management andehabilitation facilities, specialist equipment, and supplies areot in place. The dearth of rehabilitation medicine specialists ineveloping regions further complicates the issue, as does theack of national spinal cord registries. In our 3 makeshift SCInits, however, which are staffed by specialists and residents inehabilitation medicine, there were no deaths, few complica-ions, and a successful discharge for most patients. Technicaloncerns include air evacuation, early spinal fixation, aggres-ive management to optimize bowel and bladder care, androvision of appropriate skin care. Discharge planning requiresubstantial external support because SCI victims must ofteneturn to devastated communities and face changed vocationalnd social possibilities. Successful rehabilitation of victims ofhe Pakistan earthquake has important implications. The expe-ience suggests that dedicated SCI centers are essential after aatural disaster. Furthermore, government and aid agency di-aster planners are advised to consult with rehabilitation spe-ialists experienced in SCI medicine in planning for the inev-table large number of people who will have disabilities after aatural disaster.Key Words: Disasters; Earthquakes; Pakistan; Rehabilita-

ion; Spinal cord injuries; Trauma.© 2008 by the American Congress of Rehabilitation Medi-

From the Spinal Rehabilitation Unit, Armed Forces Institute of Rehabilitationedicine, Rawalpindi, Pakistan (Rathore, Ahmad); Department of Biochemistry andolecular Biology, Army Medical College, Rawalpindi, Pakistan (Farooq); Ortho-

aedic Surgery Department, Combined Military Hospital, Panno Aqil, PakistanMuzammil); Spinal Rehabilitation Unit, Caulfield General Medical Centre, Baysideealth, Melbourne, Australia (New); and Department of Physical Medicine, Univer-

ity of Michigan, Ann Arbor, MI (Haig).No commercial party having a direct financial interest in the results of the research

upporting this article has or will confer a benefit upon the authors or upon anyrganization with which the authors are associated.Reprint requests to Farooq A. Rathore, MBBS, Armed Forces Institute of Reha-

ilitation Medicine, Abid Majeed Rd, Rawalpindi, Pakistan 46000, e-mail:arooqrathore@gmail.com.

e0003-9993/08/8903-00032$34.00/0doi:10.1016/j.apmr.2007.09.027

ine and the American Academy of Physical Medicine andehabilitation

ATURAL DISASTERS FOLLOW no rules. All have thepotential for devastating social, medical, and public health

onsequences. Earthquakes can cause mass casualties, wide-pread property destruction, and disruption of essential com-unity services.1 They often affect regions of the world that

ave limited resources with which to respond to mass casual-ies.

On October 8, 2005, at 8:52 AM PST, an earthquake mea-uring 7.6 on the Richter scale occurred in northern areas ofakistan and India. It was the most devastating and debilitatingatural disaster in Pakistan’s history. More than 73,000 peopleere killed and 126,000 were injured.2

This article focuses on the lessons learned from, and thehortcomings in, the management and rehabilitation of largeumber of patients with spinal cord injury (SCI) in Pakistanfter that earthquake.

SCI is among the most devastating conditions known toankind. In Pakistan, the chronically disabled are generally

isrespected and rarely function as useful members of society,fact that presented an additional challenge in managing the

undreds of traumatic SCI patients after the earthquake. Be-ause there is no SCI registry in Pakistan, an accurate assess-ent of the number of people who sustained an SCI cannot beade, but estimates are that it was between 650 and 750.3-5

In general, Pakistan—and its medical community in partic-lar—coped very well with the challenges presented by thealamity, but mistakes were made and shortcomings ex-osed.5-8 It is therefore appropriate to appraise our manage-ent of the SCI victims to improve systems and processes and

e better prepared for future disasters. Some of the authors hadrst hand experience in the rehabilitation of SCI patients inifferent hospitals in the twin cities of Islamabad and Rawal-indi in the months after the earthquake. We also had interac-ion with physicians and other health professionals who werenvolved in the evacuation and acute management of SCIatients.

EVACUATION EFFORTS

ack of Spinal Trauma Evacuation ProtocolsSpinal trauma is a surgical emergency that requires special-

zed care in the initial immobilization and transport of a patient.ovement of the spinal column must be restricted to avoid

reating neurologic injuries additional to those produced by thenciting trauma.9 Unfortunately, after the earthquake, there wassually little such care taken in transporting patients with auspected or diagnosed SCI.

In the Western world, the spinal board is an establishedeans of extrication and efficient transport in the prehospital

hase of trauma management.10 The boards, however, werearely used in the aftermath of the Pakistan earthquake. In

vacuating patients by road, all types of vehicles—from private

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ars to buses and trucks—were used; they are totally unsuitableor transporting SCI patients. These circumstances inadver-ently resulted in worsening neurologic and vertebral damagend, in many instances, resulted in an incomplete SCI becom-ng a complete SCI. One patient gave the following descriptionf his experience:When the earthquake happened, I was struck on my backby the falling debris and had a severe backache whenrescued from the rubble. I walked to the Neelum stadiumand waited for my turn to be rescued. When the painbecame unbearable I (laid) down. I still remember whenpeople lifted me from my feet and arms to put me in thehelicopter. I could hear my back snap and suddenly I wasnumb from the waist down and couldn’t move my lowerlimbs. They told me, after 3 days in Rawalpindi, that I hada broken back.

Sadly, the majority of the health care providers involved inhe search, rescue, and evacuation efforts were totally unawaref the concept of log rolling and the correct immobilizationechniques for transporting the injured who had suspected orctual SCI.

ir Evacuation of CasualtiesThe choice of evacuation mode in SCI depends on the

atient’s condition and local settings.11 After an earthquake,elicopter transport is the preferred method for evacuatingasualties and supplying medical resources.12,13 The use ofelicopters can significantly reduce transportation times, espe-ially when ground ambulances are hindered by impassableoads.14

The earthquake struck remote communities that are nearlynaccessible even in the best of times. With the existing roadsestroyed, only air transportation was possible. A helicopterescue operation was launched immediately after the earth-uake and served as both a supply lifeline and as a means tovacuate survivors. The airlift capabilities in Pakistan wereastly inadequate; therefore, international help was sought. Theesponse was generous and immediate. Of the many Pakistanind international helicopters available, only 2 to 3 were airmbulances with medically trained aircrews. Once placed onhe helicopters, patients often were crowded together, stretchedut on the floor, to utilize every inch of space.The overriding priority was to triage and evacuate as many

asualties as possible during daylight because only a fewircraft were equipped to fly at night. In a time of chaos, withn overwhelming number of injured, the rescue operation suc-essfully evacuated thousands of casualties from the disasterone directly to tertiary care hospitals in the twin cities, wherehey had early access to specialty medical and surgical ser-ices. This may have contributed to the low mortality of SCIatients.

nique Epidemiology of SCIThere is little in the literature about the epidemiology of SCI

s a result of earthquakes; however, its epidemiology in thisarthquake has been recently reported.15 Important highlightsre: (1) the ratio of males to females injured was of 1:1.3; (2)he mean age of the injured was 28 years, with 16.5% of allnjured being less than 18 years old; (3) paraplegia was theominant level of SCI (89%), with no cases of completeetraplegia reported; (4) air evacuation (83%) and spinal fixa-ions (75%) in a large number of patients; and (5) there were noeaths among the SCI patients who were cared for by teams ofehabilitation specialists. These findings are in contrast to the

ypical epidemiology of traumatic SCI.15-19 o

rch Phys Med Rehabil Vol 89, March 2008

INITIAL TREATMENT EFFORTS

ack of an SCI RegistryBecause Pakistan had no national SCI registry when the

arthquake occurred, there is no accurate assessment of thexact number of people who sustained an SCI. In fact, veryittle is known about the epidemiology of SCI in Pakistanefore the earthquake because only 3 studies have been pub-ished.16,20,21 The attempt by the National Data Registrationuthority to document SCI in the initial post-earthquake periodas a fair effort, but it had some major flaws. These included

he following: (1) data collection was done by data entryperators rather than by health professionals; (2) instead ofocumenting injury level and degree of completeness, the onlynformation entered was “spinal trauma, back trauma, SCI,”hus making an accurate analysis difficult; (3) some patientsho were bed bound and unable to move their lower limbsecause of bilateral pelvic fractures or severe blunt muscularrauma to the back were also mistakenly included in the SCIatabase; and (4) the survey was carried out in the first feweeks after the earthquake within a specific time period. It isossible that patients with SCI who reported late were notncluded in this database. Also, SCI patients who died beforehe survey would not have been included.

ack of Spinal Units and Rehabilitation SpecialistsSpinal units were established in the West as early as Worldar II; these units were dedicated to the treatment and reha-

ilitation of SCI patients in order to manage their needs in aomprehensive manner.22 Unfortunately, this was never a pri-rity for governments, health bureaucrats, or health profession-ls in Pakistan. The emphasis has been on surgical interven-ions after SCI and on giving advice about exercises at homefter discharge from treatment. At the time of the earthquake,part from the Armed Forces Institute of Rehabilitation Med-cine (AFIRM), no other hospital in the twin cities had an SCIehabilitation unit. Although neurosurgical departments werelready established in nearly all the major teaching hospitals,edicated spinal units using a multidisciplinary approach toehabilitation were not. The paraplegia center at Hayatabad,eshawar, is making commendable efforts to address this;owever, the center’s main focus is on physical therapy (PT),nd has not had the involvement of rehabilitation medicinepecialists.

The situation described above had important implicationsecause SCI patients had to be cared for in makeshift paraple-ia centers. At the Melody Rehabilitation Center and Paraple-ic Center, District Headquarters Hospital (DHQ), many SCIatients were placed on charpoys (traditional beds of wovenwine), which are totally unsuited for SCI patients (fig 1). Also,hey were mobilized after spinal fixation without spinal braces.his resulted in many avoidable complications. The Aghahan University trauma team from Karachi noted that para-legic patients were the most neglected of all patients injuredn the earthquake.8

At the time of the earthquake, there were few qualifiedeurosurgeons and spinal surgeons in Pakistan, but rehabilita-ion medicine specialists were even less common. In a countryf 160 million people, the number of fellowships in physicaledicine and rehabilitation was less than 20. The majority of

atients with SCI were taken to hospitals in the twin cities,owever, initially there was not 1 rehabilitation specialist inhese hospitals who could facilitate SCI rehabilitation. Medical

fficers and house officers were in charge of paraplegia centers

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n many places, with the only SCI medical specialists beingeurosurgeons who acted only as visiting consultants (table 1).The clinical impressions of those of us who worked in the

win cities was that patients who received nonspecialized careere inadequately assessed, had longer lengths of stay, poorer

unctional outcomes, and an increased incidence of avoidableomplications such as pressure ulcers and urinary tract infec-ions, compared with patients treated by the rehabilitation spe-ialists. Rehabilitation medicine specialists from AFIRM vis-ted these centers to encourage the use of proper rehabilitationechniques so as to reduce the likelihood of SCI complications.

nadequate and Inaccurate AssessmentThe assessment of SCI has been standardized by the Amer-

can Spinal Injury Association (ASIA) grading system, whichs a widely accepted system that describes the level and extentf injury based on a systematic motor and sensory examinationf neurologic function.23 A thorough, accurate, and well-doc-mented neurologic examination at the primary hospital isaramount. Ironically, many physicians involved in the care of

ig 1. SCI patients being managed on traditional charpoys in Mel-dy Rehabilitation and Relief Center. Pressure ulcers are visible onoth heels of the patient and were frequent complications in pa-ients being managed in temporary spinal rehabilitation centers.

Table 1: Main Spinal Units in th

Name of Center Locatio

Neurosurgery department PIMS, IslamabadSurgical department NIHd, Islamabad

Melody Rehabilitation andRelief Centre*

Renovated Melody cine

Neurosurgery department Holy Family hospital, R

Paraplegia center District Headquarters HRawalpindi

Spinal unit Armed Forces InstituteMedicine, Rawalpind

Female surgicaldepartment*

Military Hospital, Rawa

Surgical department Combined Military Hos

bbreviations: NIHd, National Institute for Handicapped; PIMS, PakistanFor female patients only.

CI patients were unaware of the ASIA system and its work-heet documentation. This resulted in errors in the diagnosis ofomplete and incomplete SCI. The difference between a com-lete and an incomplete SCI is the presence of sacral sparing asdentified by anal sensation.24 Many patients, however, wereot examined for these symptoms.This resulted in inaccurate assessments, with ASIA grade B

r C being reported as a complete injury, or a patient beingescribed as having C6 paraplegia. Rehabilitation physiciansddressed this problem by teaching ASIA scoring and SCIssessment to doctors working in the makeshift paraplegiaenters, and by distributing the Standard Neurological Classi-cation of Spinal Cord Injury worksheets.Functional assessment is important in monitoring the out-

omes of rehabilitation interventions. Apart from AFRIM,here FIM instrument25 scoring was done, no other center

ystematically recorded functional outcome.

sychologic SupportPost-traumatic stress disorder, depression, insomnia, anxi-

ty, substance abuse, and domestic violence have been reportedfter major disasters.26-28 Temporary symptoms are more com-on than severe long-term reactions,27 however, the psycho-

ogic sequelae can persist for years.29 This earthquake resultedn physical and psychologic trauma for those who sustained anCI. Many survivors saw family members die, or trapped inubble, calling for help. Many mothers sustained SCIs whenhey dashed into their houses trying to save their children15;hey were the only survivors from families of 8 to 10 members.espite this, the incidence of clinically detectable depression 3onths postearthquake in a group of 187 SCI patients was only

%.15 This was probably the result of timely interventions bysychiatrists and psychologists, aided by a large number ofolunteers and social support groups. They were successful inlleviating the survivors’ fears and addressing their psycho-ogic needs. Notable among these groups were the Organiza-ion for Rehabilitation of Disabled Persons, the Mental Healthentre at Military Hospital Rawalpindi, and teams of psychol-gists employed by the World Health Organization (WHO).

eligious and Spiritual SupportReligion plays a pivotal role in the lives of millions of people

n Pakistan. Tragedies and calamities compel people to turn tood, seeking solace in their religion. The role of religious

ke of the Pakistan Earthquake

Primary Responsibility

Neurosurgery teamNeurosurgeon team and orthopedic

teamIslamabad Gynecologist assisted by visiting

neurosurgeonspindi Neurosurgeons and medical

officerstal, Medical specialists, medical

officers, and neurosurgeonsehabilitation Rehabilitation medicine specialists

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rganizations in the search and rescue operations just after thearthquake has been acknowledged both inside Pakistan and byhe international community.30-33 Workers from religious or-anizations followed up on patients admitted to hospitals. Pa-ients were comforted and counseled to cope by using theireligious teachings for inspiration. This helped alleviate theense of loss, especially for paraplegic mothers who wereoncerned about the future care of their children (in 1 case, a8-year-old mother of 7 who had T12 ASIA grade A SCI). Aluda, a religious organization that promotes Islamic knowl-

dge among women of Pakistan and that has no political orectarian agenda, did a commendable job of counseling womenith SCI at the National Institute for Handicapped (NIHd)

pinal unit and other paraplegic centers in the city.

SPINAL REHABILITATION ISSUES

CI Rehabilitation Brought to ForefrontSome of the greatest clinical advances in the care of SCI

atients in the last half century have been in rehabilitation.34

CI rehabilitation leads to better outcomes and should betarted as early as possible.35,36 Rehabilitation medicine is stilln its infancy in Pakistan and is often confused with PT. Thearthquake resulted in its being recognized as an importantomponent in the continuum of care of SCI patients afterurgical intervention. There was a realization that optimalutcome after SCI depends on specialized rehabilitation inter-entions by rehabilitation medicine specialists.

stablishment of Spinal UnitsPatients admitted to an SCI center early after injury are less

ikely to develop complications than are those who are admit-ed later.37 An important positive outcome of the earthquakeas the establishment of temporary and makeshift spinal units

n Islamabad and Rawalpindi (see table 1). Some were up-raded to permanent spinal rehabilitation units, but many ofhese temporary centers were closed after 6 to 8 months. Only(the spinal unit at NIHd and the Pakistan Institute of Medicalciences satellite hospital at NIHd) are currently functioningnder the auspices of WHO; they have approximately 150npatients. These are fairly basic units with an enormous needor improvements. Nevertheless, they are a great help to para-legic subjects who still cannot return to their homes located inhe hilly terrains of Kashmir and are inaccessible by roads.

There is a realization now among the surgical and the wideredical community that SCI management does not end with

pinal fixation and that rehabilitation is necessary to ensurerevention of complications and successful integration of theatient into society.

nternational SCI AssistanceThe earthquake was a unique learning experience for all who

ere involved in the rescue and management of casualties. Ints wake, it brought to Pakistan SCI rehabilitation teams fromround the world. These teams, which included physical ther-pists, occupational therapists, orthotists, and psychologists,orked with the local doctors, allied health staffs, and otherealth care professionals. They conducted courses and trainingn SCI rehabilitation. In many instances they provided usefulatient education materials for future use. Especially notableere teams from Australia, Canada, Cuba, France, Switzer-

and, South Africa, and Turkey, as well as from Handicapnternational and the International Committee of the Red

ross. 1

rch Phys Med Rehabil Vol 89, March 2008

ISSUES WITH FOLLOW-UP

nadequate Patient Education and CounselingPatient education is not a strong component of the Pakistani

ealth care system. Patient educational materials about SCIritten in the local language (Urdu) were nonexistent at the

ime of the earthquake. A commendable job was done in thisegard by WHO when it prepared and distributed an SCIatient education manual in Urdu. A limitation in providingritten information, however, is that it is not personalized to

ach patient’s needs; also, in Pakistan, many survivors wereither illiterate or minimally educated.

Many patients who sustained a complete SCI were youngnd were concerned about their future ability to walk, work,nd marry. Health care professionals had difficulty explaininghe poor prognosis for functional recovery, especially in casesf complete SCI. Unfortunately, in many instances, giving anppropriate prognosis to SCI patients was either neglected oractfully avoided. In other cases, false reassurances were given.uture employment plans and sexual dysfunction were rarelyiscussed. Even after 1 year, many patients were unsure of theirrognoses or the implications of SCI. This has led to localractices of resorting to local hakeems and faith healers.

nadequate Monetary Support DistributionIn the wake of the earthquake, emotional spirits were very

igh. Monetary support poured in from within Pakistan androm around the world. Philanthropists and the general publicisited the SCI centers and distributed money. Unfortunately,here were no criteria for distributing money to SCI patients. Atome paraplegia shelters, patients were reluctant to be dis-harged because they feared the loss of financial support. Thisncouraged dependency rather than independence.

Many SCI patients were from poor socioeconomic back-rounds, having lived in remote and hilly rural areas in mudouses that lacked electricity, water, sewerage, or sanitation.ome had never seen electronic devices and they wasted do-ated money by buying expensive mobile phones or cassette orD players.In the later stages of the disaster relief, the government

tarted a monthly assistance plan that gave 6000 rupees (US100) to every SCI patient. No differentiation was made,owever, between those with paraplegia and quadriplegia oromplete and incomplete SCI—even though someone who wased-bound with tetraplegia would need more monetary assis-ance than a person who was mobile without assistance.

ack of Social and Vocational Rehabilitation ServicesThe main emphasis of SCI rehabilitation postearthquake was

n PT, occupational therapy, and counseling. Many patientsho were employed before the earthquake and who sustainedcomplete SCI were unable to return to work. There was no

oordinated approach to ensure a smooth transition into main-tream society. Only those people who had a neurologic recov-ry to at least ASIA grade D were able to return to theommunity and their previous employment. The overwhelmingajority of victims still in hospitals are young people with

araplegia. This is in contrast to developed countries, wherenly a small number of patients—mostly elderly—are dis-harged to institutions.38

ROLE OF AFIRMAfter the earthquake, AFIRM played a prominent role in theanagement and rehabilitation of SCI patients. AFIRM is a

00-bed tertiary care rehabilitation institute, the only one of its

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ind in Pakistan. Using a multidisciplinary approach, it pro-ides comprehensive rehabilitation services to patients withCI, amputations, stroke, pediatric disabilities, and musculo-keletal or orthopedic disorders. It has separate gymnasiumsor men and women, and its own electrodiagnosis and urody-amics departments. The affiliated orthopedic technologyorkshop manufactures spinal and upper- and lower-limb or-

hoses and splints.At the time of the earthquake, AFIRM had the largest

umber of spinal turning and tilting beds (20) in the country.ne hundred forty patients were successfully managed atFIRM in the months after the earthquake, without any deathsr major complications. It received its first earthquake SCIictim at 9:00 AM on October 9, 2005. Patients were eitherirectly admitted after evacuation from the disaster zone orere transferred for SCI rehabilitation from Military Hospital,ombined Military Hospital, and the paraplegia center DHQospital after surgical interventions. The spinal rehabilitationrotocols and services provided included prevention of pres-ure ulcers, daily individual and group exercise programs,ransfer training, gait training, wheelchair mobility skills, man-gement of neurogenic bladder and bowel, psychologic supportnd counseling sessions, patient and family education and, inelected cases, follow-up.

Consultants and residents in rehabilitation medicine werealled from combined military hospitals of Multan, Sialkot,alir, and Quetta. They regularly visited a paraplegia center

DHQ Hospital), neurosurgical ward (Holy Family Hospital),elody Rehabilitation Centre, and NIHd (Islamabad) to coor-

inate SCI rehabilitation with the care being provided by localhysicians. At discharge, every patient who was still wheel-hair dependent was provided with a wheelchair, commodehair, spinal orthoses and limb supports, walking frame, and aollater (if indicated) for better ambulation and mobility. Torovide relief for the overburdened spinal surgeons, 30 patientsere transported to United Arab Emirates for spinal fixation

nd postoperative rehabilitation.Three Pakistani rehabilitation medicine specialists living in

he United Kingdom and the United States visited AFIRM atifferent times after the earthquake. The Swiss Pak SocietySwitzerland) arranged for the distribution of 18 functionallectric stimulation units to different paraplegia centers andpinal units.

AFIRM, in coordination with the Swiss Pak Society, twicenvited spinal surgeon Max Aebi, MD, for 1-week visits toakistan, during which time he performed surgeries on SCIatients and delivered lectures. Two rehabilitation medicinepecialists from AFIRM have completed a 4-month trainingrogram in SCI rehabilitation at the Stoke Mandeville Spinalnjuries Centre in the United Kingdom; more were expected toomplete such training by the end of 2007. The Al Murshidospital in Karachi sponsors this program. Three rehabilitationedicine specialists completed a 4-month, hands-on training

rogram at the Swiss Paraplegic Centre in Nottwill, Switzer-and that was sponsored by the Swiss Pak Society.

A 2-day rehabilitation seminar, with emphasis on SCI reha-ilitation, was held at the Armed Forces Post Graduate Medicalnstitute in Rawalpindi in the last week of November 2005. Itas designed to increase awareness in the medical community

bout this important and neglected field. A 1-month refresherourse for physiotherapists was held at AFIRM in January007 in collaboration with the Swiss Paraplegic Centre. Phys-cal therapists hired by WHO to facilitate SCI rehabilitation inhe civilian sector were trained in transfer, transport, handling,

nd exercise protocols for SCI patients at AFIRM. a

Al Murshid Hospital, in collaboration with AFIRM, recentlyaunched a community-based rehabilitation program for thearthquake’s paraplegic victims in Balakot district and its sur-oundings. Patients have been identified and a center estab-ished. The program will be monitored by a rehabilitationonsultant and a resident every 3 months.

LESSONS LEARNEDWithin the methodologic limits of this report, and recogniz-

ng that circumstances in other disasters may differ from theakistani experience, we believe that people planning re-ponses to disasters should consider the lessons learned fromur experience:(1) A large number of SCIs should be anticipated in natural

disasters such as earthquakes.(2) Many SCIs could have been prevented during this

earthquake had there been an awareness of spinaltrauma evacuation protocols and there been a disastermanagement plan in place.

(3) Use of helicopters is a swift means for evacuating largenumbers of casualties from hilly terrains when the roadsare inaccessible or no longer exist after an earthquake.

(4) Adequate and early psychologic support can minimizethe mental trauma associated with such calamities. De-pending on the local culture and traditions, religiousteachings can be an immense source of comfort andsolace.

(5) SCI management does not mean spinal fixation or brac-ing alone. Only a multidisciplinary approach in a ded-icated spinal unit can ensure accurate assessment of theproblem, tailored management, and successful reinte-gration into the society.

(6) Governments alone cannot deal with natural disasters.The results would be much worse in situations wherethere is no international assistance or participation ofcivilians in rescue efforts.

(7) SCI rehabilitation is only complete when the patientre-enters society as a useful member, rather than beingtrapped indoors, and seeking only monetary support.

In Pakistan, there was inadequate community-based rehabil-tation infrastructure for SCI patients before the earthquake.his seriously hampered the vocational and social rehabilita-

ion of these patients.

ecommendations for the FutureWe offer the following recommendations, based on lessons

earned from the earthquake, which can hopefully be general-zed to other earthquake-prone areas.

International responses. Many countries have disasterlans in place and many such plans have been extensivelyevised in light of Pakistan’s experience. The expense involvedn carrying out meaningful large disaster drills is a problem foroor countries such as Pakistan. Hurricane Katrina demon-trated how even the United States’ emergency response floun-ered when faced with a disaster that was of a lesser magnitudehan the Pakistan earthquake.

The following is suggested as an exemplary internationalffort. There must be a 1-window operation, so the Unitedations (UN) is the obvious choice to coordinate the operation.e propose a UN standing rapid response disaster team, with

ountries pledging to provide and maintain the required equip-ent and manpower. There should be an international accred-

tation mechanism for team medical personnel. Five yearlynternational disaster drills should be conducted under UN

uspices. The disaster team must have the capacity to mobilize

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ithin 24 hours and to sustain its rescue operation for up to aaximum of 4 weeks. International help to poor countries of

he world in the form of health care education and facilities isecessary to enable them to better cope with disasters in theirwn lands.Disaster plans are very much akin to battle plans in that they

ear little resemblance to what actually happens in the field.till, they instill a sense of order and purpose in the proceed-

ngs and hence are indispensable.Although people came from all around the world to help,

ubstantial assistance from major rehabilitation societies in theest was conspicuously missing. Two years after the earth-

uake, Western rehabilitation societies have yet to play theirole in helping their professional colleagues in Pakistan. Re-abilitation societies and SCI associations in the developedountries need to focus on developing countries such as Paki-tan by offering exchange programs, training health care pro-essionals, and providing educational audiovisual aids.

National responses. There is a need to increase disasterreparedness and have a tangible disaster management plan inlace and periodic disaster drills. This may “reduce mortalityfter a serious earthquake.”39(p443)

Trauma management in disasters and the correct SCI evac-ation, immobilization, and transport protocols should beaught during the training of emergency relief workers, ambu-ance officers, army medical staff, resident surgeons, and emer-ency physicians. Rescue units trained in methods to avoid andinimize spinal injuries should be established. They should bepart of the rapid response teams that can be deployed by air

n such calamities.Helicopters should be the preferred means for transporting

CI injured from remote areas after major disasters.As previously highlighted by Ali Sheikh, the “medical com-unity should undertake the task of teaching undergraduateedical students, postgraduate doctors, nursing, and all para-edical staff by holding workshops, symposia and as part of

urriculum as how to act at the time of natural calamity andow to work with disaster management team.”40(p747)

A database of the SCI patients injured in Pakistan’s 2005arthquake should be maintained, preferably at AFIRM, inollaboration with the Earthquake Reconstruction and Rehabil-tation Authority, WHO, and the Pakistani government. Theutcomes of the SCI victims of the earthquake should beollowed up and studied on a long-term basis.

Efforts should be directed toward establishing SCI units thatould use a comprehensive multidisciplinary rehabilitation

pproach, including the sexual, psychologic, social, avoca-ional, and vocational aspects, rather than focusing on spinalurgery or neurosurgical units.

Mental health support is needed after severe disasters, espe-ially for people who have a major disabling injury such asCI. It should be available for varying periods. Importantomponents of this process should be to explain the prognosisf SCI and to provide patients and families with relevant SCIducation.

There is a need to devise and implement a comprehensiveommunity-based rehabilitation program tailored for these SCIatients, the majority of which live in hilly terrain with roadsnaccessible even by 4-wheel drive vehicles.

Above all, there is a dire need to improve the number ofeople trained in rehabilitation medicine in Pakistan.

CONCLUSIONSThe 2005 Pakistan earthquake was a devastating tragedy that

ad long-lasting effects and left haunting memories. The med-

cal community was successful to a large extent in managing

rch Phys Med Rehabil Vol 89, March 2008

undreds of SCI casualties because of its collective zeal toeliver its best efforts under the circumstances. This would notave been possible without the timely and generous support byivilians and the international community.

Rescue and medical teams arrived from within and outsidehe country. In a minor but significant proportion, their enthu-iasm vastly surpassed their capabilities. There was no mech-nism for accreditation or evaluation of medical personnelnd/or their skill levels. One of the authors observed that somef our Western colleagues who were accustomed to working inophisticated hospitals were unable to function in the aftermathhaos when removed from their familiar environment.

Given the overwhelming numbers of casualties, the remote-ess and inhospitability of the terrain, and the loss of infra-tructure, the evacuation effort was a marvel of internationalooperation. There is, of course, room for improvement inriage and evacuation protocols. Nonetheless, if such a situationccurs elsewhere, rescue and medical personnel would do wello achieve what was achieved in Pakistan in October 2005.

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