Saving Starfish—Managing Wounds After the Haitian Earthquake
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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.
1. The World Bank. Available at: www.worldbank.org. Accessed: July 11, 2010.
2. US Department of State. Available at: http://www.state.gov/r/pa/ei/bgn/1982.htm. Accessed: July 11, 2010.
3. Haiti raises earthquake toll to 230,000. Available at: http://www.washingtonpost.com/wp-dyn/content/article/2010/02/09/AR201002.... Accessed: July 11, 2010.