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Consensus Statements Regarding the Multidisciplinary Care of Limb Amputation Patients in Disasters or Humanitarian Emergencies: Report of the 2011 Humanitarian Action Summit Surgical Working Group on Amputations Following Disasters or Conflict

  • Lisa Marie Knowlton (a1), James E Gosney (a2), Smita Chackungal (a3), Eric Altschuler (a4), Lynn Black (a5), Frederick M Burkle (a6), Kathleen Casey (a7), David Crandell (a8), Didier Demey (a9), Lillian Di Giacomo (a10), Lena Dohlman (a11), Joshua Goldstein (a12), Richard Gosselin (a13), Keita Ikeda (a14), Andree Le Roy (a15), Allison Linden (a16), Catherine M Mullaly (a17), Jason Nickerson (a18), Colleen O'Connell (a19), Anthony D Redmond (a20), Adam Richards (a21), Robert Rufsvold (a22), Anna LR Santos (a23), Terri Skelton (a24) and Kelly McQueen (a25)...


Limb amputations are frequently performed as a result of trauma inflicted during conflict or disasters. As demonstrated during the 2010 earthquake in Haiti, coordinating care of these patients in austere settings is complex. During the 2011 Humanitarian Action Summit, consensus statements were developed for international organizations providing care to limb amputation patients during disasters or humanitarian emergencies. Expanded planning is needed for a multidisciplinary surgical care team, inclusive of surgeons, anesthesiologists, rehabilitation specialists and mental health professionals. Surgical providers should approach amputation using an operative technique that optimizes limb length and prosthetic fitting. Appropriate anesthesia care involves both peri-operative and long-term pain control. Rehabilitation specialists must be involved early in treatment, ideally before amputation, and should educate the surgical team in prosthetic considerations. Mental health specialists must be included to help the patient with community reintegration. A key step in developing local health systemsis the establishment of surgical outcomes monitoring. Such monitoring can optimizepatient follow-up and foster professional accountability for the treatment of amputation patients in disaster settings and humanitarian emergencies.


Corresponding author

Corresponding Author: Lisa Marie Knowlton, MD, MPH Division of General Surgery, University of British Columbia, 910 West 10th Avenue, Room 3100, Vancouver, British Columbia Canada V5Z 4E3, E-mail:


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1.World Health Organization. World Report on Disability. 2011. Available at: Accessed on 24 June 2011.
2.World Health Organization/Pan American Health Organization: Guidelines on International Foreign Medical Teams. Proceedings of the WHO/PAHO technical consultation on International Foreign Medical Teams (FMTs) Post Sudden Onset Disasters (SODs). Havana, Cuba. 7-9 December 2010.
3.Working Groups Background Paper: Accountability, Quality Control and Reporting. Proceedings of the WHO/PAHO Technical Consultation on International Foreign Medical Teams (FMTs) Post Sudden Onset Disasters (SODs). Havana, Cuba. December 7-9, 2010.
4.Working Groups Background Paper: Registration, Certification and Coordination. Proceedings of the WHO/PAHO Technical Consultation on International Foreign Medical Teams (FMTs) Post Sudden Onset Disasters (SODs). Havana, Cuba. December 7-9, 2010.
5.Landry, MD, O'Connell, C, Tardif, G, Burns, A. Post-earthquake Haiti: the critical role for rehabilitation services following a humanitarian crisis. Disability and Rehabilitation, 2010; 32(19): 16161618.
6.Gosney, JE Jr. Physical Medicine and Rehabilitation: Critical Role in Disaster Response. Disaster Medicine and Public Health Preparedness, 2010;4(2):110112.
7.Merin, O, Nachman, A, Levy, G, Schwaber, MJ, Kreiss, Y. The Israeli Field Hospital in Haiti – Ethical Dilemmas in Early Disaster Response. N Engl J Med, 2010;362(38): 13.
8.Keane, M, Pack, ME, Greenough, PG, Buckle, FM Jr: The professionalization of humanitarian health assistance: report of a survey on what humanitarian health workers tell us. PrehospDisast Med. 2009;24(Suppl. 2):s2046.
9.Bradt, DA, Drummond, CM: Professionalization of Disaster Medicine – an appraisal of criterion-referenced qualifications. PrehospDisast Med. 2007;22(5):360–8.
10.McQueen, K, Parmar, P, Keane, M, Broaddus, S et al. : Burden of Surgical Disease: Strategies to manage an existing public health emergency. PrehospDisast Med. 2009;24(Suppl. 2):s22831.
11.World Health Organization: WHO Best Practice Guidelines on Emergency Surgical Care in Disaster Settings. 2005. Available at Accessed 14 March 2011.
12.World Health Organization: WHO Surgical Care at the District Hospital. 2003. Available at Accessed 02 March 2011.
13.Gianou, C, Balden, M, (eds). War Surgery Vol 1. Geneva: International Committee of the Red Cross, 2009.
14.Betrancourt, B, Dufour, D, Jensen, SK, et al. . International Committee of the Red Cross. Surgery For Victims of War. Geneva: 1998. Available at Access 01 March 2011.
15.US Army Borden Institute. Care of the Combat Amputee. 2009. Available at Accessed 01 March 2011.
16.International Campaign to Ban Landmines Working Group on Victim Assistance. Guidelines for the Care and Rehabilitation of Survivors. 1999. Available at Accessed on 11 March 2011.
17.Amputation Coalition of America. Experts Reach Consensus on Amputation Techniques for War Injuries. 2008. Available at Accessed on 07 March 2011.
18.Amputation Surgery Education Center. General Principles of Amputation Surgery. Available at Accessed on 12 March 2011.
19.Handicap International. The rehabilitation of amputees victims of landmines. 2006. Available at Accessed on 28 Feb 2011.
20.United States Department of Veteran Affairs/Department of Defense. Guidelines: Rehabilitation of Lower Limb Amputation. 2010. Available at Accessed on 19 Feb 2011.
21.American Academy of Orthopedic Surgeons. Clinical Practice Guidelines. Available at Accessed on 07 March 2011.
22.Sphere Project: Sphere Handbook: Humanitarian Charter and Minimum Standards in Disaster Response. 2011. Available at,english/. Accessed 14 April 2011.
23.International Association for the Study of Pain. Pain Clinical Updates: Pain and Rehabilitation from Landmine Injury. 1998; 6(2). Available at Accessed 27 Feb 2011.
24.Poçan, et al. . Crush syndrome and acute renal failure in the Marmara earthquake. Mil Med (2002) vol. 167 (6) pp. 516–8.
25.Oda, et al. . Crush syndrome sustained in the 1995 Kobe, Japan, earthquake; treatment and outcome. Ann Emerg Med (1997) vol. 30 (4) pp. 507–12.
26.Missair, A, Gebhard, R, Pierre, E, Cooper, L, Lubarsky, D, Frohock, J, Pretto, EA Jr. Surgery under Extreme Conditions in the Aftermath of the 2010 Haiti Earthquake: The Importance of Regional Anesthesia. Prehosp Disaster Med. 2010 Nov-Dec;25(6):487–93.
27.Buckenmaier, et al. . Continuous peripheral nerve block for battlefield anesthesia and evacuation. RegAnesth Pain Med (2005) vol. 30 (2) pp. 202–5.
28.Neal, et al. . ASRA practice advisory on local anesthetic systemic toxicity. RegAnesth Pain Med (2010) vol. 35 (2) pp. 152–61.
29.Size, M, Soyannwo, OA, DM, Justins: Pain Management in Developing Countries. Anesthesia. 2007;63(Suppl 1):3843.
30.Lohman, D, Schleifer, R, Amon, JJ. Access to Pain Treatment as a Human Right. BMC Med. 2010;8:8.
31.Brennen, F, Carr, D.B, Cousins, M: Pain Management: A Fundamental Human Right. Anesthesia and Analgesia. 2007;105(1):205221.
32.Craven, R: Ketamine. Anesthesia. 2007;62(Suppl 1):4853.
33.Bonanno, . Ketamine in war/tropical surgery (a final tribute to the racemic mixture). Injury (2002) vol. 33 (4) pp. 323–7.
34.Schnittger, T: Regional anesthesia in Developing Countries. Anesthesia. 2007; 62(Suppl. 1):4247.
35.Hayes, et al. . Perioperative intravenous ketamine infusion for the prevention of persistent post-amputation pain: a randomized, controlled trial. Anaesth Intensive Care (2004) vol. 32 (3) pp. 330–8.
36.World Health Organization: WHO Model List, 16th ed (updated). 2010. Available at Accessed 14 Mar 2011.
37.American Society of Anesthesiologists Task Force on Acute Pain Management. Practice guidelines for acute pain management in the peri-operative setting: an updated report by the American Society of Anesthesiologists Task Force on Acute Pain Management. Anesthesiology. 2004;100:15731581.
38.Bone, et al. . Gabapentin in postamputation phantom limb pain: a randomized, double-blind, placebo-controlled, cross-over study. RegAnesth Pain Med (2002) vol. 27 (5) pp. 481–6.
39.Bloomquist, . Amputation and phantom limb pain: a pain-prevention model. AANA J (2001) vol. 69 (3) pp. 211–7.
40.Barbosa, et al. . Neuraxialanaesthesia for lower-limb revascularization. Cochrane Database Syst Rev (2010) (1) pp. CD007083.
41.Martin, et al. . Severe phantom leg pain in an amputee after lumbar plexus block. RegAnesth Pain Med (2003) vol. 28 (5) pp. 475–8.
42.Scheman, et al. . Flashback and nightmares after surgery under neuraxial anesthesia: a report of two cases. Arch Phys Med Rehabil (1998) vol. 79 (5) pp. 579–81.
43.Buckenmaier, C. Defense and Veterans Pain Management Initiative. The Military Advanced Regional Anesthesia and Analgesia Handbook. 2008. Available at Accessed 18 April 2011.
44.Ramachandran, VS, Rogers-Ramachandran, D, Cobb, S. Touching the phantom limb. Nature. 1995 Oct 12;377(6549):489–90.
45.Chan, BL, Witt, R, Charrow, AP, Magee, A, Howard, R, Pasquina, PF, Heilman, KM, Tsao, JW. Mirror therapy for phantom limb pain. New Engl J Med. 2007 Nov 22;357(21):2206–7.
46.Ramachandran, VS, Altschuler, EL. The use of visual feedback, in particular mirror visual feedback, in restoring brain function. Brain. 2009 Jul;132(Pt 7):1693–710.
47.O'Connell, C, Shivji, A, Calvot, T. Handicap International Report: Earthquake of 12th January, 2010 – Haiti: Preliminary Findings About Persons With Injuries. 29 Jan 2010. Available at Accessed on 18 Feb 2011.
48.Gawande, A. Casualties of War – Military Care for the Wounded from Iraq and Afghanistan. N Engl J Med. 2004;351:24712475.
49.Clasper, JC. Regional anesthesia, ballistic limb trauma and acute compartment syndrome. JR Army Med Corps. 2010 Jun;156(2):77–8.
50.Mannion, SJ, Chaloner, E. Principles of war surgery. Br Med J 2005; 330:14981500.
51.Cummings, D. Prosthetics in the developing world: a review of the literature. ProsthetOrthot Int. 1996;20:5160.
52.Lisa, I, IezzoniMD, MSc MD, MSc, and Laurence, J. Ronan, MD. Disability Legacy of the Haitian Earthquake. Ann Intern Med. 2010;152:812814.
53.Eitel, S. Haiti Mission Report Feb-Mar 2010. USAID. Available at Accessed 25 April 2011.
54.ISPO consensus conference on appropriate orthopaedic technology for low-income countries: conclusions and recommendations. ISPO Technologies 2001. Available at Accessed 25 April 2011.
55.USIS Prosthetics and Orthotics Program Guide. Implementing P&O Services in Low-Income Settings. USISPO 2010. Available at Accessed 25 April 2011.
56.Appropriate Prosthetic and Orthotic Technologies in Low-Income Countries 2000-2010. USAID/ISPO 2010. Available at Accessed 25 April 2011.
57.US International Society for Prosthetics and Orthotics. USISPO Develops Code of Conduct for Humanitarian Assistance. Available at Accessed 26 April 2011.
58.Jacobson, E.An Introduction to Haitian Culture for Rehabilitation Service Providers. CIRRIE Monograph Series 2003 [Online]. New York: Buffalo University Press. Available at Accessed 24 April 2011.
59.Ingstad, B. and Reynolds White, S. (eds.). Disability and culture. 1995. Berkley: University of California Press.
60.World Health Organization. Violence and Injury Prevention and Disability: Community-Based Rehabilitation Guidelines. 2011. Available at Accessed 23 April 2011.
61.International Committee of the Red Cross. Haiti: thousands of disabled Haitians to benefit from rebuilt clinic. Available at Accessed 15 March 2011.
62.Potter, BK, Scoville, CR. Amputation is not isolated: an overview of the U.S. Army amputee patient care program and associated amputee injuries. J Am AcadOrthop Surg. 2006;14:S188S190.
63.Charlton, E: The management of post-operative pain. Update in Anaesthesia. 1997;7(23):17.
64.Chu, K. Improving Effective Surgical Delivery in Humanitarian Disasters: Lessons from Haiti. PLOS Medicine. 2011;8(4):14.



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