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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.