On January 12, 2010, a 7.0-magnitude earthquake in Haiti caused a massive humanitarian disaster. In addition to widespread devastation of homes and buildings, there was a nearly total collapse of Haiti's governmental infrastructure and healthcare system. More than 200,000 people died, and over 1.2 million were left without shelter.1 Many injuries were high-energy trauma from collapsing buildings.2 Before the earthquake, Haiti was already one of the poorest countries in the Western hemisphere, with 72 percent living on less than $2 a day (U.S. dollars)3 and with the poorest health statistics in the region. The average yearly income is just $560.4
The benefits of limb salvage are still debated, but it is acknowledged that it comes at a cost.5–8 The operative management is complex and time-consuming with its own potential morbidity.5,6,8,9 The role of primary amputation is still discussed,10,11 despite some evidence for improved quality of life after reconstruction and a lower overall cost to the healthcare system.6,11,12 Outcomes at 2 years for limb salvage12 are at least similar to those of amputees, who are more likely to require retraining and invalidity pensions than limb salvage patients.13 These studies compare the likely recovery in the developed world where there is ample access to rehabilitation and prostheses.
Although there is evidence for potentially good rehabilitation after amputation in the developing world,14 there is still a risk that after amputation individuals will struggle economically with or without a prosthesis. If a significant percentage of the population lacks the capacity for physical labor, there is a potential for decreased productivity and slowed economic growth. Prostheses are expensive, and many amputees in the developing world cannot afford to purchase them, let alone maintain them.15,16 Even a prosthesis manufactured by an aid organization, such as the International Committee of the Red Cross, can cost $1000 to fit and fabricate.17 Consequently, there is a need for limb salvage in the developing world, particularly when there are large numbers of individuals affected, such as in major disasters. It is, however, resource-consuming, a time when health care is scarce.
Medical Emergency Response International (MERLIN) is an aid organization specializing in health that intervenes in times of crisis, helping to rebuild shattered health services. The organization has long-term experience in emergency relief and began to develop experience in limb salvage in Indonesia in 2004 and Kashmir in 2005. After the earthquake in Haiti, the British Association of Plastic, Reconstructive, and Aesthetic Surgeons looked for a partner to provide a limb salvage team. Medical Emergency Response International had already mobilized a response and, by January 15, 2010, had a preliminary team on the ground, opening a tented hospital on January 20, 2010.18 A description of the work carried out is presented, providing an insight into the difficulties and successes of a limb salvage team working in an adverse environment.
A field hospital was established on a tennis court in Delmas 33, a suburb of Port-au-Prince. The hospital operated from January 20, 2010, until the planned closure for surgery 10 weeks later. The hospital and its facilities evolved during this time period. The data discussed here were collected from the operative records from January 20, 2010, to March 12, 2010—8 days to 8 weeks after the earthquake. The hospital consisted of a single operating tent (initially with one table for the first 10 days and then two tables for the next 6 weeks), a procedures room, and four ward tents catering to up to 40 patients (Fig. 1).
The surgical team consisted of a plastic surgeon, an orthopedic surgeon, and one or two anesthetists. Two operating room nurses provided both surgical and anesthetic cover. A nurse ward manager coordinated a team of local nurses. The medical staff rotated at intervals from between 10 days to 1 month. During the period of data collection, there were five plastic surgeons, five orthopedic surgeons, and five anesthetists. An experienced plastic surgical nurse was present during weeks 2, 4, and 5 to provide a wound and dressing service.
The hospital was listed on the United Nations health cluster list of facilities detailing its capability and patient criteria. Referrals came via this central coordination and from relationships built following visits to other hospitals.
The cut-off point for data analysis was chosen after a drop-off in earthquake-related injuries was observed. After this time, the operative workload decreased appreciably toward the planned closure of the hospital.
The population treated was purposefully limited almost exclusively to those with earthquake-related trauma. The predominant method of injury was crush injury.
A total of 348 operations were carried out on 158 patients during the study period; 46 patients (29 percent) were children and 112 (71 percent) were adults.
An average of 47 operations (range, 30 to 62) were performed per week; an average of 36 (range, 17 to 57) had anesthetic support and an average of 10 (range, 0 to 26) did not. The average number of operations per day was eight (range, three to 18). The proportion of patients requiring anesthetic dropped over time, with 39 of 44 needing a general anesthetic in week 2, decreasing to 17 of 43 in week 7 (Fig. 2).
Procedures by Specialty
Plastic surgery or soft-tissue procedures accounted for 253 (73 percent) of 348 operations; 63 (18 percent) were combined orthoplastic cases (soft tissue and bone) and 24 (7 percent) were orthopedic (bony) cases. The proportion of cases needing orthopedic input fell from 16 of 44 (37 percent) in week 2 to three of 43 (7 percent) in week 7 (Fig. 3); 24 (80 percent) of 30 bone manipulations or fixations took place in the first 3 weeks of the hospital's existence.
Types of Procedures
The most common procedure was the dressing change, accounting for 131 of 348 cases (38 percent). The number of dressing change procedures rose in the latter weeks, accounting for six of 44 (13 percent) in week 2 and 33 of 43 (73 percent) in week 7.
There were 82 wound débridements (19 percent) and 77 split skin grafts (18 percent). Twenty-four (15 percent) of 158 patients underwent bone manipulation or fixation (six external fixations, eight internal fixations, and 12 fracture manipulations; two patients underwent fracture manipulation before subsequent fixation). Sixteen (10 percent) of 158 patients required a flap to cover exposed bone. All of the flaps were pedicled, as there was no possibility of performing free tissue transfer. Eighteen (11 percent) of 158 patients treated were referred with complex defects or exposed bone on a limb. These cases included 13 lower leg defects and five upper limb defects. Twelve of these 18 cases underwent successful reconstruction.
There were only six amputations (4 percent) in this series (three below-knee amputations, one above-knee amputation, and two digital amputations). However, 36 (10 percent) of the total number of operations (n = 348) were to aid healing in amputation stumps in 10 patients, eight of whom had had their amputations elsewhere.
Number of Operations per Patient
Of the 158 patients treated, 136 (86 percent) had an operation with anesthetic support; the other 22 patients (14 percent) were treated under local anesthetic only. Of those who required an anesthetic, 83 (53 percent) of 158 had only one operation; 75 (47 percent) had multiple procedures, ranging from two to a maximum of 16.
Of the 348 operations, 265 (76 percent) had anesthetic support; 144 (54 percent) of 265 operations were performed using general anesthesia. The majority of these operations were ketamine-based, although our records do not allow us to quantify this; 97 (37 percent) of 265 procedures were performed with the patient under regional anesthesia [63 (24 percent) under spinal anesthesia and 34 (13 percent) under upper limb block]. The remaining 24 procedures (9 percent) were carried out with the patient under sedation; 74 (51 percent) of 144 general anesthesia procedures took place in children, despite the fact that they accounted for only 29 percent of the population treated.
Sixteen (10 percent) of 158 patients suffered complications, including one fatality. A 22-year-old woman presented with a heavily contaminated and infected open knee wound. She had Eisenmenger syndrome with signs of biventricular failure and suffered with progressive desaturation after procedures to decontaminate and débride the wound and provide soft-tissue coverage. She was cared for perioperatively by an experienced cardiac anesthetist. Despite this, her condition deteriorated, and following several unsuccessful attempts to move her to a facility with intensive care, she died on February 4, 2010.
Of the 16 patients who suffered complications, two had their primary operation carried out elsewhere. Nine (12 percent) of the 77 skin grafts required regrafting, including grafts in two patients who required regrafting twice. There were four infections—two soft-tissue infections and two bony infections. The soft-tissue infections resolved after débridement and antibiotics. The bony infections were settled after 3 months of intravenous antibiotics. There were two amputations for failed limb salvage—one after extensive lower limb necrosis following compartment syndrome and the second after débridement of an open calcaneal fracture with bone loss and necrosis that made the limb unsalvageable. One partially failed flap was rescued by skin grafting of the residual defect, and there was one hematoma (Fig. 4 and Table 1).
There are marked difficulties in the immediate response to a massive humanitarian disaster. In mass casualty situations, the demands on the surviving medical infrastructure exceed the capacity of the surviving personnel or facilities. There will always be a preference to provide the maximum immediate benefit to the maximum number of people.19 Despite this, with the timely mobilization of appropriate emergency medical teams, efforts can be resourced for the potential longer-term gain of limb salvage. This study gives valuable information on the range and frequency of procedures over time that can be used to help prepare for any future emergencies and demonstrates a low amputation rate for the patients treated.
Arguments for limb salvage in wealthy countries are good.6,11–13,15,16 In poor economies with no support infrastructure, these arguments become stronger, as the human and economic consequences of limb loss can only be worse.15,16 Extremity injury is common, accounting for a high proportion of patients seeking medical advice after earthquakes,20–22 and the benefit of supplying plastic surgeons in the field in the acute response after earthquakes has previously been stated.23 These extremity injuries can be complex, requiring a combined orthoplastic response.24 It was our impression that during the early weeks there were very few plastic surgeons mobilized as part of the response. The role of plastic surgeons in the early stage of disaster relief is increasingly being recognized,25 and our experience parallels the experience after the Turkish earthquake23,26 and was echoed more recently after the earthquake in Chile.27
The data here show why this sort of team needs to be mobilized early. We and others28 have found that principles of trauma management remain the same in the field, with staged wound care, ensuring adequate débridement to achieve a well-prepared wound, particularly in the absence of microbiological back-up. The basic principles of plastic surgery were applied in the initial stages of the response; the most useful tools were the simple tools, including a reliable hand dermatome and reliable sterilization. Despite the fact that the facilities were not conducive to free tissue transfer due to the lack of equipment and suitable facilities for aftercare, options for suitable soft-tissue coverage were found for the vast majority of patients. If a free flap was the only option for salvage, the resource curve was changed in favor of amputation. Of the four lower limb amputations, two might have been salvageable with free tissue transfer. Local reconstructive options of fasciocutaneous flaps and muscle flaps proved useful in covering defects; 80 percent of the bony manipulation or fixation was carried out in the first 3 weeks. The proportion of orthopedic/combined procedures fell over time. This does not reflect the overall orthopedic workload, as there was a steady increase in delayed fractures seen in the outpatient setting. Nearly all of these patients were treated nonoperatively in the first instance before referral if necessary to a facility with laminar airflow, which was viewed as a more suitable facility for performing delayed internal fixation. As patients improved over time, the numbers of dressing change procedures rose over time, from six in week 2 to 33 in week 7. Similarly, the number of operations carried out with anesthetic support decreased over time, due to the decreasing invasiveness of the procedures.
Severe open fractures are a major challenge, regardless of the facilities or situation.29 This is compounded in the developing world with poor access to healthcare and rehabilitation services.30 The Haitian government estimates that 6000 to 8000 persons lost digits or limbs.31 The expected amputation rate in a mass casualty situation is difficult to assess. After the earthquake in Pakistan in 2005, the overall amputation rate was given as 1.6 percent of patients attending an emergency facility.32 The actual amputation rate, however, in those admitted with lower limb injuries was 16 (6.2 percent) of 258. Rates of amputation vary from 3 percent of all patients admitted following earthquake injuries21 to 10 percent (18 of 176) for extremity injuries.20 The amputation rate in this series was six (4 percent) of 158 patients, which compares favorably to these series.
Revisions after emergency amputations are often needed to make the limbs suitable for prosthetics.33 In this series, 10 percent of the operations dealt with wound-healing problems in amputations in patients who largely had their amputations performed elsewhere. Prosthetic limbs need replacement every 3 to 5 years (or sooner in children), and crutches are more likely to be used than artificial limbs.16 Few patients in Haiti had access to prostheses even before the earthquake,34 and it is envisaged that this will only get worse, despite the strong presence of charities, such as Handicap International. Haiti has few rehabilitation professionals and little capacity to manufacture essential assistive technologies, including prostheses and wheelchairs.35
The social cost of amputation needs consideration. After amputation following landmine injury, adults were up to 40 percent more likely to have difficulty in providing food for the family. For children, their future becomes even more uncertain, and they are likely to always remain dependent on others.15 However, even in the industrialized world, where there is good access to quality prostheses, there is increasing evidence that patients with salvaged limbs, although perhaps requiring longer initial treatment, are more likely to return to their previous employment than are amputees.12
Both the United Nation Stabilization Mission in Haiti and the Haitian government suffered greatly in the earthquake, leading to an extended period of confusion. Once “on the ground,” teams were faced with multiple challenges in establishing an ethical and practical response to the disaster,36 including establishing referral pathways for the sourcing of patients as well as for patient disposal for longer-term rehabilitation. This dilemma is exemplified by the single fatality in this series. The logistical challenges were complex, and worksite conditions were difficult. The hospital evolved rapidly, however, with changing surgical teams able to replenish supplies or bring in needed equipment.
Careful and considered advance planning could avoid any future need to depend on this ad hoc supply. The British Association of Plastic, Reconstructive, and Aesthetic Surgeons and Medical Emergency Response International have now embarked on this process, aiming to produce a list of suggested supplies that would be useful in the emergency response. A register of reconstructive plastic and orthopedic surgeons with an interest in limb salvage is also being developed, including anesthetists and operating room staff who would be willing to respond in a coordinated fashion. There have been calls to develop a wider, coordinated international response.39 It is conceivable that medical and surgical equipment could be prepositioned at airfields around the world along with temporary shelters, rations, and water supplies so that most places could be reached within 8 hours after notification, including the equipment needed for an orthoplastic limb salvage team.
If reconstruction is provided, there will often be a need for multiple revisions, including the possible long-term treatment of osteomyelitis.6,7,12,37 Access to surgical services in Haiti before the earthquake was already patchy.38 It is difficult to envisage how these revision procedures will be carried out unless there is long-term commitment from both local and international health providers and specialists. Furthermore, as the bulk of the medical facilities and Haiti's only medical school were destroyed, the need for long-term commitment is even more acute.39
To our knowledge, these data are the first published series of outcomes of a limb salvage team in acute disaster response. This experience shows that a favorable amputation rate can be achieved, and the changes in workload over time demonstrate the benefit that an orthoplastic limb salvage team can provide in the early stage of disaster relief.
The authors wish to acknowledge the many people who helped in this response contributing to the establishment and running of the hospital, including many Haitian nationals and nonnational Medical Emergency Response International (MERLIN) staff. The authors thank Dr. Franklin Ackom and Lloyd Donaldson from MERLIN for their helpful review of the article. This article is dedicated to the memory of Lloyd Donaldson, who helped pioneer limb salvage teams as part of the emergency response. Funding for the MERLIN relief effort and for the hospital was received from a variety of charitable sources. The authors would like to acknowledge the substantial contribution from the Department for International Development, the Disasters Emergency Committee, the Swedish International Development Agency, and the Emergency Response Relief Fund (United Nations Office for the Coordination of Humanitarian Affairs, Haiti). They thank all of the other MERLIN donors.
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