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Messages from Haiti

By: Maureen Leahy

By Maureen Leahy

The capacity crowd at Thursday’s symposium, “The Haitian Earth­quake: What We Saw, Did, and Learned,” listened intently as AAOS members who have served rotations in Haiti recounted their experiences in informative and, at times, poignant presentations.

The 2-hour symposium, moderated by J. David Pitcher Jr., MD, also featured Robert J. Caudle, MD; Fernando E. Vilella-Hernandez, MD; David S. Feldman, MD; Greg A. Zych, DO; Christopher M. Jobe, MD; John Lovejoy, MD; Carlos Lavernia, MD; James N. Gladstone, MD; Christopher T. Born, MD; and Hans Larsen, MD.

“By the end of this week, it’s estimated that 350 AAOS members will have participated in the relief efforts in Haiti,” Dr. Pitcher said as he invited the volunteers in attendance to stand in recognition of their efforts. “Additionally, we recognize the countless others who have gone with us and those who have made our efforts possible by filling in the gap here at home.”

Early challenges
Dr. Pitcher, chief medical officer of Project Medishare, arrived on the third day after the earthquake and spent a total of 11 days in Haiti spread over two visits. He described the progression of patient mortality and morbidity during the first weeks after the quake and how it modified physicians’ response.

“Although orthopaedic surgical injuries predominated initially, infectious disease and public health issues quickly surfaced as equally important medical problems,” Dr. Pitcher said. “The progression of these surgical and medical problems is most instructive.”

Several orthopaedic surgeons arrived in Haiti before emergency healthcare facilities were established and before supplies had been shipped, making treating patients extremely challenging. With the hospitals in Port-au-Prince destroyed, makeshift operating rooms had to be constructed. Anesthesiologists were forced to rely on regional anesthesia because oxygen supplies, electrocardiogram machines, pulse oximeters, and blood pressure cuffs were in short supply or nonexistent. Medical equipment and supplies were virtually nonexistent, and the local medical workforce had suffered major casualties.

“By day 3, it was quite evident that the logistical challenges of responding to a disaster would be our greatest challenge,” said Dr. Pitcher.

Many patients had open fractures that required immediate attention. “Of 200 patients, 25 had grade IIIB open tibial fractures and many more had lesser grade open tibial fractures,” he said. “During a 32-hour period of time on days 3 and 4, we applied 180 splints and washed all the wounds with hexachlorophene and applied dressings.”

Communicable diseases such as tuberculosis, meningitis, suspected cases of H1N1 flu, chicken pox, and measles were seen by week 2. The physicians were also faced with cases of pulmonary emboli, accidents, and malnutrition.

“The daily progression of surgical needs mirrored the daily progression of morbidity and mortality,” said Dr. Pitcher. “Initial efforts in such a massive disaster should focus on the immediate stabilization and irrigation of fractures and wounds.”

“Early operative intervention using regional anesthetic techniques can conserve postoperative monitoring resources,” he added. “External fixation and wound VACs [vacuum-assisted closures] are useful by day 4, and the judicious closure of wounds with skin grafting requiring dermatomes can be expected by the second week. Fracture and wound care will predominate after this, as will the rehabilitative efforts including prosthetic fitting.”

Refining the relief effort
Just 39 Haiti orthopaedists serve a country of 9 million people. In addition to an overwhelmed workforce, other challenges faced by orthopaedic volunteers serving in Haiti included a “decimated infrastructure, a traumatized population, and difficult communication,” said Dr. Caudle, who treated patients at St. Damien’s hospital located on the outskirts of Port-au-Prince.

“The events in Haiti are an opportunity for change, but how do we max­imize this opportunity?” he asked.

“We need to encourage continued involvement of our membership,” he said. “Go to Haiti yourself or en­cour­age a colleague to go, sponsor a nurse’s trip, or make a donation to the Surgical Implant Generation Network (SIGN). Finally, involve the Haitian people—that’s the future, it’s needed, and it’s the right thing to do.”

In-country resources, experience, and supplies
Based on his team’s experience in a trauma facility they established within a hospital 70 miles northeast of Port-au-Prince, Dr. Lovejoy stressed the importance of assessing the availability and the capabilities of in-country resources, including facilities, supplies and equipment, and personnel. Keys to success in this area, he said, involve “knowledge of the facility and an accurate assessment of its capabilities, experienced teams, maximizing equipment and minimizing waste, teamwork, and above all, good organization.”

Similarly, Dr. Jobe addressed the advantage of previous in-theater experience in disaster relief efforts. These physicians can share important information about what to expect in terms of infrastructure and supplies, medical and surgical background, and culture.

Dr. Lavernia’s organization, Operation Walk Haiti, concentrated on getting needed supplies to Haiti. “Our mission is to effectively deliver people and supplies for the orthopaedic reconstruction of Haiti for the next 10 to 20 years. I am in it for the long run,” he pledged.

It’s also his goal to keep interest in the Haitian recovery strong, to work with the Haitian government, and to develop an effective distribution network within Haiti.

Ethics, safety, and the civilian/military blend
Dr. Feldman, who worked with Partners in Health (PIH) in Port-au-Prince, spoke of maintaining ethics and safety in medical crisis situations. Specifically, he addressed the ethics of triage, surgery, human conduct, and discharge and follow-up, and safety for the surgeon, the medical team, and the patient.

During international disaster relief, it’s important to “maintain your own and your patients’ safety, keep your humanity, be your own barometer for ethics, unify your groups and nationalities as soon as possible, and create order from chaos,” he said.

“Civilian trauma systems are rooted in military medicine,” explained Dr. Vilella-Hernandez, adding that “the combination, collaboration, and integration of civilian and military resources and expertise, although challenging, can provide the essential components to disaster response and preparedness.” In addition, “effective, reliable, and streamlined communication is a must to understand each others’ capabilities and allow for the sharing of resources.”

Long-term commitment and future mobilization efforts
“Although the acute crisis in Haiti has passed, the need for ongoing and sustained long-term care continues,” Dr. Gladstone told the audience. “To give Haiti and Haitians a chance, we need to commit for the long term. We need to work hand-in-hand with the Haitian doctors providing help, support, and training when and where necessary.”

Moreover, he said, “we need to identify the most functional hospitals and clinics where complex procedures can be performed most safely and effectively, and make sure patients, manpower, and supplies are directed there.”

Dr. Gladstone called upon the volunteers to continue to donate their expertise, to encourage colleagues in all specialties and fields to do likewise, and to encourage industry to continue their generous donations.

“Civilian medical practitioners and organizations may have useful skill sets and want to get involved in disaster response, but we don’t have a system for integrating them,” said Dr. Born. He outlined the following priorities for change:

  • disaster education
  • a centralized database of credentialed individual medical providers
  • prepositioned memorandums of understanding (MOUs)
  • integrating industry into relief efforts
  • developing a centralized inventory database
  • standardizing equipment
  • developing a civilian liaison office in the Department of Defense

He suggested that it might be useful for a specialty society, such as the AAOS, to serve as “uber” coordinator of these efforts.

Dr. Zych offered suggestions for the Orthopaedic Trauma Association (OTA) and the AAOS to improve involvement in future disasters. For example, he said, an annually updated prospective database of orthopaedic volunteers would be helpful, as would obtaining the global positioning system coordinates of major medical facilities in earthquake-prone countries. Education on how to deal with severe crush injuries, how to handle delayed compartment syndromes, and how to stabilize fractures with minimal materials and equipment is also needed.

“It would also be important to invite foreign medical units to share their experiences with earthquake injuries,” he said.

Following the AAOS member presentations, Dr. Hans Larsen, president of the Société Haitienne de Traumatologie et d’Orthopedie, described Haiti’s current capabilities and needs.

“The Haitian people will be forever grateful for the aid of the AAOS, the Pediatric Orthopaedic Society of North America, the OTA, and other international societies,” Dr. Larsen said. “Now, we have to face the aftermath. To succeed, our continued efforts will have to be creative, pragmatic, and realistic.”

At the conclusion of the program, Dr. Larsen and theother panelists took questions from the audience.

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