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Reply to Letter to the Editor: Critically Assessing the Haiti Earthquake Response and the Barriers to Quality Orthopaedic Care

Sonshine, Daniel, A., BA1, 2, 3, a; Caldwell, Amber, BA3, 4; Gosselin, Rich, A., MD, MPH, MSc2, 3, 5; Born, Christopher, T., MD6; Coughlin, Richard, R., MD, MSc3, 4

Clinical Orthopaedics and Related Research: February 2013 - Volume 471 - Issue 2 - p 692–693
doi: 10.1007/s11999-012-2685-9
Reply to Letter to the Editor

1 Weill Cornell Medical College, New York, NY, USA

2 Institute for Global Orthopaedics and Traumatology, University of California, San Francisco, San Francisco, CA, USA

3 Orthopaedic Trauma Institute, San Francisco General Hospital, 2550 23rd Street, Building 9, 2nd Floor, 94110, San Francisco, CA, USA

4 Department of Orthopaedic Surgery and Institute for Global Orthopaedics and Traumatology, University of California, San Francisco, San Francisco, CA, USA

5 School of Public Health at University of California, Berkeley, Berkeley, CA, USA

6 Department of Orthopaedic Surgery, Brown University and Rhode Island Hospital, Providence, RI, USA

a e-mail;

(Re: Sonshine DB, Caldwell A, Gosselin R, Born CT, Coughlin RR. Critically assessing the Haiti earthquake response and the barriers to quality orthopaedic care. Clin Orthop Relat Res. 2012;470:2895-2904.)

An erratum to this article can be found at

We thank Dr. Moyad for his constructive criticism and service to the Haitian people. His positive experience providing care in the wake of this natural disaster is testament to the power of volunteerism in resource-poor countries. After the earthquake, many medical and surgical volunteers sacrificed to provide the highest quality care to disaster casualties. These stories and tremendous worldwide response should give all of us hope regarding our international capacity for relief.

Nevertheless, the intention of the publication was to provide our readership with a perspective that has remained largely elusive. Although many publications regarding the orthopaedic response to the Haiti earthquake document the quantity of procedures performed and the personal stories of the volunteers, there are few systematic documentations of the failures. Our systematic method of data collection and analysis has many weaknesses highlighted in the publication, but it provides an important window into potential ways in which we can improve and devise measures of disaster care.

Many of the anecdotes associated with poor-quality care, we believe, were preventable with training. From our interviews, for example, we discovered that ill-prepared physicians such as ophthalmologists and pediatricians were performing orthopaedic surgeries without adequate training. In addition, to address Dr. Moyad’s specific point regarding fasciotomies, there is documentation to suggest that this procedure should be reconsidered in the acute muscle-crush compartment syndromes commonly found in earthquake zones. The muscle in these limbs usually is already dead and in these resource-poor settings, when damage-control orthopaedics is necessary, there is limited time for repeated operations that risk limb-threatening infection [2].

Although we will never know the specific nature of every injury treated, there clearly is room for debate and greater need for better documentation and further study of disaster response. A substantial report from the Pan American Health Organization (PAHO) discusses the overall lack of organization and chaotic pattern of the relief effort [1]. The foreword of the report states that the response, “included a number of wholly unprepared or even incompetent health actors who bypassed the overburdened coordination mechanisms”.

For these reasons, the PAHO report highlights the need for accreditation and training in disaster response, a matter about which we disagree with Dr. Moyad. Regardless of the outcome, training courses provide volunteers with the opportunity to share stories, exchange knowledge, build expert opinion, and prepare for a variety of patient-care possibilities. We hope that formal training courses are cultivated to continue to improve the care provided to patients most in need.

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1. de Goyet de Ville C, Sarmiento JP, Grunewald F. Health response to the earthquake in Haiti: lessons to be learned for the next massive sudden-onset disaster. Washington, DC: Pan American Health Organization; January 2010. Available at: Accessed October 15, 2012.
2. Reis, ND. and Better, OS. Mechanical muscle-crush injury and acute muscle-crush compartment syndrome: with special reference to earthquake casualties. J Bone Joint Surg Br. 2005; 87: 450-453.
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