By: 1 April 2010

We arrived into Haiti three weeks from the devastating earthquake of January 12th that destroyed most of the Haitian capital of Port-Au-Prince. Of the 4 million city residents nearly 3 million were affected with 300,000 injured & 400,000 living in open spaces.

The magnitude of this earthquake was 7.0 on the Richter scale. However the devastation caused was immense compared to the subsequent massive earthquake in Chile which measured 8.8 on the Richter scale. Therefore the impact of a disaster is proportional to the vulnerability of those who are affected. The poor are always the most vulnerable due to over crowding & poor infrastructure. There is no consensus on the number of deaths but it is agreed that between 200,000 – 230,000 people lost their lives.

Who are we?
'UK Med' is a charity born out of such disasters. The charity is headed by Professor Tony Redmond Hospital Dean of Salford Royal & Professor of International Emergency Medicine. Its members are NHS consultants from varying fields who have worked in war zones & in natural disasters over the last 20 years. With this charity I have been to operate in earthquake hit regions of Kashmir 2005, China 2008 & Indonesia 2009.

Acute response for Haiti
Once the extent of the disaster was appreciated a worldwide call for doctors, especially Orthopaedic surgeons, was issued by the UN & Red Cross. MERLIN one of the DEC (Disaster Emergency Committee) charities had approached 'UK Med' to send a team of surgical specialists to set up a hospital in Haiti. DEC is an umbrella organisation set up by the government to collect relief funds from the general public & then to spend the money among themselves on the basis of clinical need & priority. This system is also important from the point of view of preventing duplication of effort & working together to achieve the given aims.

Our team included Consultant orthopaedics, a Consultant plastic surgeon, two specialist theatre nurses, a specialist burns nurse/manager, a consultant anaesthetist and a logistician. The 8 hour bus journey from Porto Domingo to Haiti was both fascinating and tiring. This road was the only 'humanitarian corridor' that connected the republic with Haiti. All other means of transportation was disrupted. Communication was patchy and little information was coming through even at this stage. The contrast between Haiti and its neighbour the DR (Dominican Republic) could not be starker. Impressive colonial buildings, loud blaring music and smiling faces compared with sad eyes broken bodies & devastated homes. In some areas of the capital 90-95% of the homes were destroyed. Large banners erected around the makeshift camps begging for food & water showed the extent of their desperation.

We reached Port-Au-Prince in the dark and one strained their eyes to look for signs of the devastation caused. As you drew closer to Port Au Prince you regularly saw collapsed buildings. I was later told that most of the school buildings and hospitals had collapsed due to poor workmanship with a considerable loss of life. We arrived at our campsite late in the evening. For the last four weeks the whole city had been without running water, food, electricity and sanitation. The people had grown impatient waiting for the aid to arrive; emotions were high and tempers flaring. There was a sense of urgency as the security situation was precarious and the advice from UN was not to venture out after dark. The tents were erected and we all collapsed in our tents looking forward to starting work the next morning.

Tent Hospital in Port-Au-Prince
Most of these disasters occur in hilly terrain and far flung area which are generally poorly accessible. Each disaster is different and understanding the needs of each is important in planning the humanitarian response. Our earlier experiences in Kashmir 2005, China 2008 and Indonesian earthquakes 2009 were entirely different. In all these places the Federal infrastructure was intact, providing the back bone for any emergency and subsequent rebuilding process. Here the government and the social infrastructure had collapsed due to the sheer scale of the disaster. Therefore all the essential equipment required to undertake such a mission had to be airlifted from outside, starting from the tents to X-ray machines, respirators and water purification plants.

In Haiti it was clear that most local hospitals had been badly damaged and a hospital was needed to treat the injured in this vast Metropolis. This is where working with a large organisation like MERLIN had its advantages as constructing a tent hospital would be a big undertaking requiring logistics, assessments and planning. Once constructed it would need expansion and constant replenishing of resources that only a big organisation could provide. The work in a disaster like this could be divided in acute and delayed response. Patients' lives and limbs saved by emergency surgery will require many more months of painful reconstructive surgeries and rehabilitation. Teams of doctors and nurses are required to go on a short rotation to provide the continuity of care until the host infrastructure has recovered enough to undertake this work.

MERLIN's tented hospital in Port-Au-Prince

Our tent hospital was set up in a tennis court situated in Delmass 33, a poor area and heavily populated part of Port Au Prince. We were on the main road that snakes through this deprived area to end close to the sea front. Most other Non Governmental Organisations (NGO's) like MSF (Medecins Sans Frontieres) had set up hospitals along this narrow corridor.

This hospital was an example of Anglo-American co-operation in managing the hospital. We worked closely with Irish charity called GOAL and an American NGO called IFM (International Faith Missions). The Irish team consisted of A&E consultants, an anaesthetist, a retired ophthalmologist and nurses. While the American group consisted mainly of nurses and young volunteers. The tent hospital consisted of three main areas. The entrance lead to the triage area where on one side medical emergencies were treated, while on the other side a minor surgery area looked after wound dressings and debridements. The second area was the Operating theatre suite with an adjacent recovery and three further tents housed pre and post op patients. Central to this was the tent that housed administration staff and logistics. The only surviving hut served as the store room of the medical supplies including medications and surgical instruments. The Irish and the Americans looked after the triage and managed the medical emergencies. Our team took on the responsibility of running the theatres and post operative care.

An important lesson learned early from other disasters is to involve the local workforce to give them a feeling of ownership and pride in the project. Therefore a number of locals were employed in the day-to-day running of the hospital. While a team of Haitian nurses were employed to run the hospital at night.

Every two weeks, up until three months, a surgical team consisting of two surgeons, anaesthetist and nurses arrived from UK at this hospital to provide continuity of care.

Type of injuries in an Earthquake
Injuries sustained can be varied. The biggest number of injuries is simple fractures and soft tissue injuries which can be adequately treated with dressings and splinting. Most intrabdominal, chest or head injuries are usually fatal. Very few are diagnosed properly and lack of facilities or even training can be a cause of this high fatality rate. In China for example, multi-storey buildings housed most schools and accommodations facilities. As a result we saw a large number of thoraco-lumbar fracture dislocation and calcaneal fractures from jumping from a height. However the main orthopaedic injuries involve limbs including severe muscle-crush injury and open or neglected fractures.

Asad Syed in the operating theatre

Earthquake an Ortho-plastic Emergency
Most fractures in natural disasters are open fractures. A number of these walking wounded are inadequately treated. The overlying soft tissue envelope is crushed and lost at the time of injury or excised during debridement of devitalised tissue. While life threatening injuries take precedence, a number of simpler fracture configurations are inadequately treated, splinted and advised to seek help later. A number of these become infected; soft tissue envelope deteriorates further requiring skin graft, rotation flaps or free flaps after skeletal stabilisation. Published literature confirms that in order to minimise the rate of amputations or complications definitive plastic procedure has to be performed within 5-6 days of skeletal stabilisation.

During our stay our surgical team operated on between 30-35 patients. The plastic and Orthopaedic surgeon worked together on two tables simultaneously with two anaesthetists. There are clear advantages of this approach. Both can share from the experience of the other and valuable time can be saved with the orthopaedic surgeon performing debridement and skeletal stabilisation and then giving way to the plastic surgeon for soft tissue cover. This allows definitive surgery to take place in one go – a one stop shop. A number of operations were carried out over the 10 day period. These included open fractures requiring wound debridement, External fixator with skin flaps or grafts, open reduction internal fixation of neglected fracture dislocations, amputations, skin grafts and gastrocnemius & abdominal flaps for more difficult cases.

Difference between Earthquake & Blast injuries
It is important to make a distinction between crushed limbs from falling masonry or subjected to a gun shot or blast injury. The treatment of both differs radically and treating these injuries on the same line as battlefield often causes confusion and leads to a higher rate of limb amputation that may be salvaged.

EQ Injuries are mainly low velocity injuries, mostly involving the limbs. Entrapment of limbs under rubble may cause extensive muscle-crush injury leading to muscle-crush compartment syndrome. If untreated, crush syndrome characterised by hypovolemia, shock, hyperkalemia, acidosis & myoglobin related renal failure occurs. Muscle can resist vascular ischemia for up to four hours. However, adding critical ischemia to mechanical entrapment between two compressing surfaces above the diastolic blood pressure will accelerate this process and muscle death will occur within an hour. At cellular level myocytes lose their ability to maintain their intracellular hyperosmolarity due to cell membrane damage leading to fluid shift from extracellular to intracellular space and seepage of intracellular potassium in the opposite direction. These events may cause hypovolaemic shock or cardiac arrest. This is further complicated by rhabdomyonecrosis leading to acute renal failure from the excess myoglobin leaked into the circulation. Death may occur within hours of extrication. It is therefore necessary to keep the patient well hydrated, reverse metabolic changes and ensure adequate diuresis. Some of these patients will also develop compartment syndrome, however the muscle has already died as a result of the crush injury. Traditional teaching is to perform urgent fasciotomy to release the

compartment pressures. However, in these cases this can be counter productive. As a sterile dead environment invariably becomes infected, not only does the dead tissue bleed excessively, but all the infected dead muscle will now have to be removed. These muscles in a closed environment would have otherwise become fibrotic. It now agreed that performing fasciotomies can lead to severe sepsis and eventual amputation. These cases of crush injury should be dealt with splintage, rehabilitation and delayed corrective surgery for contractures & clawing of toes.

Blast or gun shot injuries result from the interaction of shock wave with the body. Gas containing organs and viscera are affected. Secondary blast injury is caused by blast wave or wind and bomb fragments while the tertiary blast injury results in the body being thrown through the air. There is additional damage to skin by thermal injury. These are more serious multi organ injuries and require radical treatment like laparotomy and amputations immediately to save lives.

In natural disasters it is not necessary to perform amputations immediately. A more measured and cautious approach with initial wound debridement, even in more serious cases, and referring to centres with Orthoplastic cover can save many unnecessary amputations.

Clinical Cases
External fixation remains the main means of skeletal stabilisation. Orthofix external fixators proved to be very versatile and easy to use. These were inserted using battery operated disposable drills. The major drawback of these battery operated drills was lack of power when using them on healthy young bone. The Mini C-arm bought at the cost of £50,000 proved to be invaluable in running of the A&E and performing surgery.

Case 1: A 30-yr-old female suffered a comminuted fracture of her femur and open fractures of her metatarsals of the left hand with loss of skin. She was extricated soon after the earthquake. Her hand was operated multiple metatarsals were 'K' wired tendons reconstructed & one finger amputated. The femoral fracture was placed in a plaster until later. At three and a half weeks her lower limb was rotated, shortened & angulated. X- ray revealed a fixed deformity. In a tent hospital internal fixation is to be discouraged. Here ORIF was undertaken as a last resort. She was fixed with a Large DCP plate with satisfactory results.

Case 2: A 24-yr-old sole earner of the family had a mutilating injury to her lower limb. She had lost most of her family and was terrified of surgery. She had lost a significant amount of soft tissue from the heel and foot with multiple fractures. The foot appeared insensate and the Plastic surgeon had deemed the foot unsalvageable (see below). A below knee amputation was successfully performed and the patient fitted with an artificial limb through Handicap International.

Case 3: A 15-yr-old male presented with a neglected open fracture dislocation of ankle at three weeks. The open wound debrided and a full thickness graft applied over the area of skin loss. Ankle was stabilised using an external fixator. (see images right).

End of acute response
After successfully working for three months following the EQ the MERLIN tent hospital is being dismantled and no further surgery planned. However, specialist nurses will continue to undertake dressings and provide outpatient care for the 200-300 patients attending this hospital daily. The orthopaedic and plastics patients will be provided monitoring and support in a newly established primary health care unit next to the tent hospital.

Advice to clinicians interested in working in disaster zones

  1. Best time to salvage limbs is within the first week. Try and get in with the search and rescue teams.
  2. Join a medical charity or organisation with the ability to mobiliseat short notice
  3. Inform your hospital manager of your intention to do this kind of work. Taking leave and reorganising your commitment can be a tedious job.
  4. Keep your vaccines up to date. It can take up to two weeks for them to start protecting you.
  5. Undertake one of the Disaster Management courses to become aware of the issues surrounding a natural disaster.
  6. Only travel as a part of team to be most effective. This ensures your personal safety and maximises your productivity.
  7. Take all your essential gear with you. This may mean collecting instruments or materials over a period of time. There is no greater disappointment then to arrive at a disaster zone inadequately prepared.