In this blog series, Nikki takes over to tell us about her experience as a newly qualified physio and to describe the joys, fears and people she meets along the way. She'll also share her tips which might be useful to some of you too!
Irecently interviewed Peter Skelton, a Physiotherapist currently working for Handicap International UK as a Rehabilitation Project Manager, a charity involved in situations of poverty and exclusion, conflict and disaster.
Peter came from an international development background, working on non emergency projects mostly in sub-Saharan Africa before studying to become a physiotherapist. He was a relatively new Band 6 physiotherapist working in the NHS when he had the opportunity to go to Haiti as part of a joint response between Handicap International and CBM (an international disability charity) to the 2010 earthquake.
The 2010 earthquake in Haiti resulted in 222,570 deaths and 300,572 injured and Peter describes it as “possibly the single worst large disaster we’ve seen in the last 20 years”.
He explains how the global emergency medical response was not as well developed in 2010 and due to the scale of the earthquake in Haiti, a huge range of health professionals showed up to help. This often included junior or even pre-registration students with limited clinical or international humanitarian experience. As a result, not only was a poor job sometimes done but there were limited safety constraints for volunteers, increasing the risks faced by volunteers.
“After Haiti, a lot of lessons were learned in terms of emergency medicine and medical response”
The Haiti earthquake highlighted that there was a need for a coordinated emergency medical system to respond appropriately to a humanitarian disaster, with teams of trained, equipped and regulated professionals with systems of medical records and appropriate protocols in place. In 2013, the World Health Organisation published the Classification and Minimum Standards for Foreign Medical Teams in Sudden Onset Disasters which included specific reference to rehabilitation. Peter acknowledges that this “has been a big step forwards” as it outlines that all international medical teams have a consideration for rehabilitation, something that previously was not perceived as essential to emergency response.
A man with hemiplegia receiving rehabilitation care from a Handicap International physiotherapist, Haiti. - © Benoit Almeira/Handicap International
In reality, most international teams will arrive more than 72 hours after the event which sadly means that they are unable to offer immediate life-saving medical work. The response teams are therefore involved in life-changing medical work in terms of improving quality of life, therefore highly qualified, multi-disciplinary professionals are essential in providing a level of care to meet these requirements.
I admit that before meeting with Peter, I had not thought about this and it now seems unbelievable that prior to 2013, a very medical approach was taken when responding to humanitarian disasters was taken by many teams. Peter painted the picture…
“If you imagine you work in a really, really busy emergency field hospital, everybody’s busy, everybody’s stretched, but we’re the ones who will probably sit down and have a real half-an-hour meeting with the patient and talk through what’s happened to them, and talk through implications of their injury”.
And I agree. Not to divert attention away from the fundamental work doctors carry out in such situations, but it is easy to see the importance of a multidisciplinary team when improving the lives of those affected by such disasters.
The Project, Training and Recruitment
Since 2013, Peter has been working with UKMED, a core partner in the delivery of the UK Emergency Medical Team (UKEMT) programme funded by the Department for International Development, to develop a training package for rehabilitation professionals. Led by Handicap International, and in line with the WHO minimum rehabilitation standards for EMTs, the training package was created with input from professional networks in the UK, physiotherapists are now being trained to respond to trauma in disasters and emergencies.
Physiotherapists are now considered an essential participant in international EMTs, and, with just over 200 rehabilitation professionals now trained, the UK Emergency Medical Team are leading the way.
I asked Peter how long the training would take; “It depends how keen you are!”
He explained that those with the appropriate skills are selected and go on to complete humanitarian clinical training pre-deployment and deployment weekend courses. A three day highly specialised rehab training course and further day courses are also provided such as managing spinal cord injuries and amputations, developed alongside specialist organisations such as ACPIN and BACPAR.
Acute SCI training, UK - © P Skelton/Handicap International
Peter outlined that anyone with HCPC registration is able to join the register, but a minimum of 5 years clinical experience is normally required to deploy
“...in general we would only deploy people who are experienced in working in the area they would be deployed to work in”.
For example, if a therapist is deployed for the first 2 to 3 weeks after an earthquake to a field hospital, they would be major trauma specialists, however he emphasises that “they need to know that things are very, very different in a humanitarian environment”. As access to spinal surgery is unlikely, therapists would therefore require knowledge on conservative management of spinal cord injuries. Furthermore, patients more frequently present with polytrauma and consequently, an amputation would not be managed in isolation, you’re managing multiple injuries.
This differs largely from my amputee experience in the NHS. With diabetes being the leading cause of amputation in the UK, patients rarely present with multiple traumatic injuries to consider during their recovery and rehab. If deployed, you are suddenly working in a conflicting context, therefore the importance of pre-deployment training is vital in order to apply your knowledge and skills to a humanitarian situation.
Injuries associated with earthquakes Haiti 2010 - © William Daniels/ Handicap International
The role of the Rehabilitation Team
“For me, it is a dream job” - Peter discloses.
Along with the publication of the WHO Minimum Standards, this project has presented him with the opportunity to be involved in changing the humanitarian rehabilitation world and has had a global impact on the way in which rehabilitation is viewed in emergency responses.
Previously, high quality surgical and medical interventions were the only things being provided without further continuity of care, with poorly developed rehabilitation services or international organisations like HI, ICRC or CBM doing their best to meet overwhelming needs. By placing a rehabilitation professional in a field hospital within the first week, a lot more can be achieved within the acute phase. For example, providing education to the patient and their family, providing appropriate mobility aids and equipment such as proper mattresses and signposting to longer term facilities.
In a humanitarian disaster, resources may be stretched and access to care may be limited,presenting as a major challenge. The transportation of resources is a large logistical undertaking, however, as UKEMT is government capability, Peter assures me that all necessary equipment is ready to be deployed. He emphasises how important it is for international respondents not to deplete the affected country’s own resources. Medical teams, for example, are now expected to bring their own pharmacy and surgical instruments and rehabilitation teams are expected to bring their own crutches and wheelchairs.
Therefore, perhaps the challenge is not just a logistical one but a clinical reasoning one. Peter explains that the team can only bring about 12 wheelchairs at a time because they are big, bulky and take up the space that other professionals would also need, consequently, being able to ration out equipment is essential in a humanitarian crisis.
Delivery of emergency wheelchair stock, Nepal 2015 - © B. Blondel/Handicap International
Considering the staffing challenging NHS departments continually face, I wondered whether negotiating time off work for deployment would present as a challenge.
Peter explains that once you have completed your training you are on-call for a fixed period of time which would be agreed with your employer. There is then the possibility for your employer to receive funding for your post whilst you are away. Of course, it could be argued that by being deployed to an emergency environment you gain an abundance of unique skills you can bring back to your practice in the UK and the organisation encourages Trusts to recognise these benefits - Sounds like invaluable CPD to me!
Deployment is rotational, typically lasting for three weeks at a time. The team usually withdraws after three months and then NGOs such as Handicap International are able to provide longer term rehabilitation if the national health system is not able to meet the ongoing needs. I reflected on some of the challenges I face in my job as a physiotherapist in the UK, one being discharge planning. Discharge planning is often complicated enough within the NHS, let alone in a disaster setting. Again, a lot of lessons were learned from Haiti. Peter describes that due to the lack of medical records, there was no way of knowing what type of surgery was performed and therefore a lot of patients were lost in the transition from acute to the rehabilitation input from charities such as HI. To improve discharge planning, comprehensive medical records are now mandated and remain with the patient (not the health facility) while the UK training places a large emphasis on coordination: how do we link with other teams on the ground and see beyond the short term deployment of a surgical field hospital..
Sadly, it is fair to say that physiotherapists in an NHS setting manage patients in the UK with horrific stories and Peter highlighted the Manchester attacks as an example. On a daily basis healthcare professionals are working with people who have life changing injuries and in that respect, Peter draws a comparison to humanitarian situations. The main difference perhaps is the volume of patients volunteers will be expected to manage and real test is providing community level support, going into people’s homes and becoming exposed to the realities of the disaster;
“In Gaza, our teams were working with national teams and going into people’s homes to provide care…. And it was being exposed to that reality, in homes that were damaged and where family members had been killed, that was difficult.”
In collaboration with International Spinal Cord Society the first spinal cord injury specialised cell is currently being developed to be launched early next year. This includes a twenty bed facility with a multidisciplinary team who can deploy at short notice. Peter acknowledges that twenty beds is not a complete solution but he hopes it will be the foundation for further support to evolve from. He is very clear in explaining that the emphasis is not on sending out a complete spinal injury unit, but on supporting national capacity with the knowledge that after three months the international team withdraws.
For Peter, working for HI and being involved in the development of the training package for rehabilitation professionals with UKMED is a something he describes as a “dream job” and this came across throughout the interview as he talked passionately about his work. Our meeting prompted me to consider the possible challenges faced in a humanitarian disaster and allowed me to reflect on my current work in the NHS and to consider the transferable skills physiotherapists have to offer. To me, it now seems unfathomable that prior to 2013, rehabilitation professionals were not considered to be an essential part of EMTs.
Peter shared some useful websites for physiotherapists interested in becoming involved in humanitarian work.
Handicap International: www.handicap-international.org.uk
International Medical Corps UK: https://www.internationalmedicalcorps.org.uk/
International Committee of the Red Cross: https://www.icrc.org/
Médecins Sans Frontières: https://www.msf.org.uk
WCPT run a page on disaster management: www.wcpt.org
About the author
Nikki is a newly-qualified physiotherapist with a previous degree in Human Communication Sciences, currently working in a busy university hospital in East London. She was the first ever to sign up to one of our seminars when we started back in 2015; and became our first ever resident blogger a year later! You can get in contact with Nikki at firstname.lastname@example.org.