Saving Starfish—Managing Wounds After the Haitian Earthquake
First responders to calamitous events face problems that with hindsight could be avoided. Communities, organizations, and hospitals usually have a “preparedness program.” When asked by the media what I expected as a first-responder to the Haitian earthquake, I missed the mark in many ways. I’ve learned that for some tragedies, no amount of preparation is sufficient. Each day, wound care physicians see a variety of traumatic and infected wounds. In Haiti, the sheer magnitude of what we saw and the logistical problems of getting supplies to the “field” were something I could not appreciate until post-field experience and reflection.
Monna Lesperance reminded me of this fable: A boy and his father are strolling on a beach shortly after a devastating storm. The beach is littered with dead and dying starfish. The boy keeps flipping random ones back into the ocean as they walk. The father says, “Son, why are you wasting your time throwing the starfish into the ocean? There are so many of them, what difference will a few make?” As the son, in thought, throws another, he says to his father, “It will make a difference to that one.”
The World Bank places the population of Haiti at 9.8 million.1 The capital and epicenter of the earthquake had an estimated population of 2.35 million prior to the January 2010 earthquake.2 The estimate of 230,000 deceased3 fails to include the many unaccounted who were buried beneath tons of concrete littering street after street and blocking roadways throughout the city. Even now, months after the quake, hearsay from volunteers describe buildings and roadways blocked by debris, and people still buried under collapsed structures. Together with an internist, pediatrician, registered nurse, and three nurse practitioners, we arrived at the Port-au-Prince Central Hospital with only a few hundred pounds of supplies, mostly water and snacks for our own health and hydration. Other supplies were mobilized by the Hope for Haiti permanent mission in Carfou, several hours from Port-au-Prince. After quickly processing through customs, we went directly to the Port-au-Prince Central Hospital. There, with only a few buildings still habitable, and over the next several days, we provided care for hundreds of injured individuals. We worked there each day until sunset, at which time for security reasons, we were forced to leave the hospital. Electricity, water, and flushable toilets were nonexistent. The total work area available to us consisted of a space (about 60 ft x 40 ft) divided into 5 ward-like rooms able to accommodate about 10–15 patients each. As a small group, we were able to function without a leader. When we entered the hospital, the seven of us simply dispersed and began to assess the situation. The first order of business was to establish intravenous (IV) lines for hydration and medication. We had few IV set-ups and a small supply of fluids. Rolling veins, collapsed veins, and the small veins of infants and children hampered starting IVs. The nurses were an invaluable aid. They were much faster at accessing veins and getting the necessary fluids moving. We used Lactated Ringer’s and had a small supply of N-Saline. Most of the victims arrived on mats, boards, or old mattresses that were placed on the floor, so our work was often performed while on bended knee—kneepads would have been nice. A strong back would have been better. This may not be the job for the aging physician or nurse. Initially, there was no food or water for the victims and the many Haitian workers who assisted in security, cleaning, and moving the injured around. As each day passed, more and more evidence of the entrepreneurial spirit of the Haitians emerged and with it, food vendors on the streets throughout the city. We had a small supply of water from the Hope for Haiti clinic, but could not chance distributing the meager supply, which created a moral dilemma. Instrument sterility was problematic. Since the supply cartons were being organized and we needed to begin caring for the more serious wounds, we did the best we could. We found instruments such as forceps, hemostats, and dissecting scissors in the Hope for Haiti supplies but they were loose, that is, unsterilized. The best we could do, given the urgency, was to wipe each instrument in alcohol and proceed with debridement. For the first few hours, each instrument was reused after the alcohol wipe. A while later we found a few bottles of Betadine and several plastic trays. Three trays were made, the instruments rotated, and the most recently used instruments soaked the longest. Betadine was replaced with a sterilizing solution when it became available. One small, bathroom-sized room became the pharmacy to the entire central hospital but that would not have happened had the nurses (Candi and Monna) not worked tirelessly. As additional supplies came in, Candi and Monna organized the supplies and categorized pharmaceuticals. Shelves were actually cartons piled on top of one another. Finally, they taped sample vials and pills to the wall with a legend to indicate the product in the boxes below. Candi’s and Monna’s efforts saved an incredible amount of time and surely saved lives. Once IV lines were established we gave everyone a dose of antibiotic—penicillin, gentamicin, a third generation cephalosporin IV, or IM injections and oral antibiotics, when we ran out of IV drugs. The working area was divided into several wards, each with one or two of us in charge of the patient care in that particular area. Most of the patients had a variety of wounds and/or traumatic amputations but some had clear medical problems. Ultimately, each of our team had a multiplicity of responsibilities and circulated from ward to ward as particular problems emerged. Many of the abrasions were located over more seriously traumatized bone, soft tissue or viscera. Figure 7 shows an abrasion over the posterior pelvis that was evaluated for hip function and pelvic pain. Absent privacy, light, and personnel, we did not evaluate for internal injury. Moreover, we did not have radiographic availability. In addition to patients in the wards, the grassy areas and roadway streets within the hospital compound were filled with victims sleeping, living, and trying to survive. Thus, another concern was to assure that simple lacerations or abrasions would not become infected in the environment of dirty mattresses and the unfavorable conditions of unsanitary street living. In those first days after the earthquake, apart from the pervasive sweet smell of Pseudomonas and death, it did not appear that the wounds were more grossly infected. Few had purulent drainage, cellulitis, or swelling. Surprisingly, the most prominent cause for pain was in removing days-old dry dressings. Despite crush injury and traumatic amputations, there was little or no bleeding and no complaints of pain from the severed and exposed bone, muscle, and assorted soft tissues. Most individuals had limb fractures in addition to wounds. At one point we tried to create traction by passing a Steinman pin across the tibia with a hand drill. Then with gauze material tied to a jug of fluid, traction was produced when the apparatus was hung over the side of the bed. One problem with this approach was the insufficient number of pins. It is also likely that what pins we found were unsterile. Also, since most of the victims were on the floor, there was nothing for the jug to hang over. We didn’t have enough jugs to use, and even with what we did have, I doubt there was enough weight to help overcome muscle spasm and deformity. This technique was abandoned after several attempts; the hand drill disappeared overnight anyway. The limb in Figure 10 was tensely swollen with areas of necrosis. We could not determine if this was a compartment syndrome due to a crush injury or a necrotizing infection. From the appearance of the surface of the skin, it looked more like a compartment syndrome. This individual eventually went for surgery and most likely had an above-knee amputation. In an ideal situation his leg might have survived a fasciotomy and/or wound debridement. With the absence of asepsis, clean dressings, and daily wound care extending over many weeks, the amputation would be the most pragmatic approach. The time lag between field dressing and the patient arriving at the hospital was one of the most significant problems we encountered onsite. We arrived on Saturday afternoon, 96 hours after the earthquake. I cannot imagine a strategy that would have prevented the dry-dressing dilemma. Removal was excruciating for the patient and not easy for us. We tried to saturate the dressing with saline or a dilute Betadine-saline solution. Then, with surgical technique, the dressing material could be lifted one layer at a time. The process was slow and the difficulty heightened by having to work with dim lighting often while kneeling. Unfortunately, the technique met with failure most of the time. Perhaps it would have been kinder to remove the dressings more rapidly and get the pain over with? The child in Figure 11 screamed and moved too much during the initial attempt to remove the dressing. Finally, with sedation, the dressings were removed. The woman in Figure 12 had extensive pre-earthquake burns covering the legs, arms, and torso. All burns except those on the right leg were healed. Initially, without benefit of analgesics, we struggled to remove her dressings in order to deal with the infection. It took quite a bit of time and caused this woman a great deal of pain. But with constant soaking and careful removal of the material, usually a layer at a time and sometimes a fiber at a time, the dressing came off. There was considerable purulent discharge beneath the dressing, especially around the thigh. Once the dressings were off we were able to wash the tissue and reapply a fresh dressing. While we were there, we applied Silvadine on a daily basis and the process became considerably pain-free and her infection seemed to abate. This individual’s wound (Figure 13) consisted of a crush injury leaving ground-in pieces of concrete, cement dust and dirt and bone fragments. The immediate need was to excise the foreign matter and bone fragments and leave a clean wound. Most likely, this individual’s injury would result in amputation. Virtually all post-surgery individuals within our area had undergone amputation. Some of the amputations were guillotine-type with no flap provided. Others had loose flaps that could be expected to fail. In some cases, the flaps were very loose and lay directly over bone with no fat/soft tissue padding. This older gentleman (Figure 14) did not look healthy. Most likely he would have a BKA, but it seemed that with sufficient debridement and infection control, the forefoot could be debrided enough to be folded back into a flap, leaving a Symes type amputation that would provide a very functional, weight-bearing limb. Under analgesia (Duragesic lollypop), much of the loose bone and foreign body material was excised with Betadine-cleaned forceps, a dissecting scissor, and a disposable scalpel. The bone contained remnants of the metatarsal bases and crushed tarsal bones, as well as ground in cement block. The disposable scalpels quickly became dull. Suture material (3-0 Vicryl) was ready in case bleeding became an issue. Bleeding was not an issue possibly due to shock, vessel spasm, and retraction. The woman’s laceration (Figure 15) across the thigh was dirty and needed cleaning. She also had a fractured femur in proximity with the laceration. With the lower leg externally rotated, the likelihood of a hip or femoral facture was obvious. However, apart from wound care, this woman’s fracture was not attended to for the five days we were there. The priority of need dictated that more serious cases were attended to first (ie, amputations). One young man with massive internal injury was brought in. He died within a day. It seemed that the only anesthesia possible in the operating room consisted of spinal or local blocks. A few individuals had sustained head trauma, and most likely, neurological injuries (Figure 16). The most we could do was to clean the wound and request transfer of the patient. The wound depicted in Figure 17 is one that could easily be treated. There was bone exposed (fibula) at the inferior aspect of the wound. Additionally, there was a lot of muscle exposed. Granulation tissue could grow over the bone or a muscle flap rotated to provide cover over the bone. A skin graft or tissue substitute would eventually leave an epithelialized base. Two of the most prominent conditions post-earthquake (almost 6 weeks after) were infection and tetanus. We did not have tetanus antitoxin and it is unlikely that the population was inoculated. It is doubtful that the tetanus toxoid injections we provided were helpful. This woman (Figure 18) had very poor dentition. She seemed unable to speak in a coherent manner and our native language speaking team members were unable to understand her. Dr. Steve looked inside her mouth and diagnosed oral thrush. She was coughing. He suggested the presence of PCP pneumonia and put together the findings as evidence of AIDS. Eventually she was moved from the ward area, but there was no way to know if she was moved out onto the hospital grounds or sent to another care center. With reasonable supplies and environment, we were able to provide adequate wound care and save limbs like those seen in the photos. Many of the victims with traumatic limb loss (Figure 19) would require a higher-level amputation. All we could do was clean these wounds to hopefully prevent or at least delay sepsis. It was fairly simple to debride loose, dysfunctional tissue (Figure 20), but this individual languished for days without attention to his fractures. At one point, a family member accompanying him became very agitated at the days during which his fracture was unattended. The environment grew hostile and appeared to be on the verge of becoming violent. Fortunately, Creole-speaking workers were able to mediate and calm the situation. The morgue was about 100 yards down the street from the ward building. Walking toward it, one is first struck by the disorganized bodies on the roadway. But it was not the smell of death that prevented me from going closer; I had become used to that. It was the sickly, slippery, oily surface of the roadblocks felt underfoot. It must be coming from the decaying fat. We provided care for many and eased the pain of death for others. We came and gave hope to as many as we could. In retrospect, despite the uncountable loss of lives and limbs and the indescribable carnage, we were able to make a difference in the lives of few.