Reflections on the MUSC Ortho Haiti Experience

Objectives

• Briefly summarize the events and efforts by the department and local individuals to provide immediate relief in the weeks following the earthquake

• Describe Damage Control Orthopaedics and how to implement in austere environments

• Provide and discuss case presentations involving amputations, external fixation, internal fixation, skin grafting, and revision techniques

• Outline the future orthopaedic and therapy directed needs for Haiti, both acute and long term

• Suggest improvements for future disaster related relief and surgical responses

Why Haiti?

Chile - 8.8 Haiti – 7.0Japan Islands - 7.0 China/Russia/Korea 6.9

Illinois – 3.8 Offshore N CA – 5.9Papa NG – 6.2 Haiti – 5.9 Oklahoma – 4.0

Why Haiti

• January 12, 2010 Haiti sustained a 7.0 magnitude earthquake of epic proportions

• Poorest nation in the Western Hemisphere

• Just recovering from 4 large hurricanes over the last year

• Poor building infrastructure with little to no earthquake codes

Hotel Montana

SC 1st Team

• Number Operations: 45

• Types performed:

– Amputations,

– External Fixators

– Compartment releases,

– Irrigation and Debridements,

– Traction pins

• Complications

– 2 deaths ( 1 gas gangrene)

2nd from Left: Bob Belding MD, ColumbiaRick Reed MD, CharlestonMike Petrillo EMT, Hilton Head Aaron Kurtz, EMTAaron Stephens, Water Missions International

Mike Petrillo- Pilot/EMT

Bonne Finn

Les Cayes Airport

Initial Assesment- Cite Lumiere

Initial Assesment- CitiLumiere

HopitalLumiere, Bonne Finn

•Built by Lumiere Medical Ministries (Late 70’s)• Once employed close to 300 now at 125•Most employees had not been paid since last March•Was slated to close in January 2010 due to lack of funds and mismanagement

Hospital Lumiere

• Prior MUSC Medical TripsJoe Thompson

Gerald Shealy

Nathan Strauss

Shane Woolf

Todd Bell

JadDorias

Allister Williams

Frank Armocida

All Ortho Wards

Acute Conditions

• days old open

fractures and wounds

• crushed limbs (spines)

• blood loss

• severe dehydration,

• traumatic amputation, infection, delayed compartment, unstable fractures

Walking Wounded

Splinting limbs and pain relief

Casting forstable fractures

Stabilize for future surgery

Linda Leone: Necrotizing Fasciitis

Linda Leone: AKA

• Septic and near death

• Fever Resolved

• AKA, multiple debridements

• Wound Vac

• Grafted

• Often Heard singing

“How Great Thou Art”

Compere: Tetanus?

1st Team Lessons Learned

• Don’t close anything

• Rehydrate

• Use broad spectrum antibiotics

• Use Tetanus toxoid even after injury

Medical records and Communicating plans

Label on the cast or patient what was done - datewhat needs to be done

Patient carriesclinic cardX-ray

Damage control orthopaedics

– External fixators to achieve rapid stabilization and mobilization (Fixators placed emergently with no radiographs may need to be revised later)

– Most closed fractures should be managed with plaster splints, traction or external fixation.

– Open reduction and implant fixation risks converting a closed injury into an infected open injury

– Traumatic or initial amputations may need to be done at a higher level than first anticipated – revisions expected

Damage Control Orthopaedics• Orthopaedic treatment should occur when appropriate,

however patients with long bone fractures should undergo some sort of fixation to decrease the likely hood of any further respiratory compromise.

– Treatment trends have occurred in three main eras:• Early total care (ETC) – 1980s

– Early definitive fixation was the goal• Intermediate (INT) – 1990-1992

– Early fixation was still performed in most cases– Adverse outcomes such as the systemic inflammatory response in

the multiply injured patient were coming to light• Damage control orthopaedics (DCO) – 1993 – present

– Benefits of temporary stabilization with ex fix followed by conversion to IMN (when appropriate) were reported

Bone LB, Johnson KD, Weiglet J, Schneiberg R. Early versus delayed stabilization of femoral fractures.A prospective randomized study. J Bone Joint Surg Am. 1989;71:336-40.

Scalea TM, Boswell SA, Scott JD, Mitchell KA, Kramer ME, Pollak AN. External fixation as a bridge to intramedullary nailing for patients with multiple injuries and with femur fractures:Damage control orthopedics. J Trauma. 2000;48:613-23.

How Do We Follow This Up?

Who Should Go?

• Stay home if you are not fit

• Go as a team with a plan and work closely with an established and respected NGO who had programs in place before the earthquake

• Make sure someone on the team knows the language and culture

• Make sure that all personnel traveling on team have specific roles that they know. Minimize non-essential personnel to avoid taxing an already overburdened infra structure

• Expect to be a generalist and not just a specialist and be willing to work outside your training to do what is needed for the patient

Tom Horn: The Architect

Must travel with you or it will be “diverted”

Must Haves balanced with“Oughta” Haves

Leave Behinds

Surgical instruments – sterileCydex or sterilizersIV fluids – extra for irrigationPain medication – local, regional, oralAntibiotics – IV and oralBandages, betadine, glovesCasting supplies and splints

What to take

Medshare Supplies Anesthesia/Respiratory• Circuit Bags• Ambu bags• Tracheal kits• CPR/ Anesthesia masks• Oxygen Masks/Tubing• Airways• Tracheal tubes• Breathing circuits• Drainage/Suction• Closed Wound Suction• Evacuator (Hard)• Closed Wound Suction• Evacuator (Soft)• Salem Sump (Naso Gastric• tube)• Yankauer tips• Drains (flat/round)• Penrose drain• Drainage/Collection Bag

Drapes• Impervious• General• Small Drapes• Paper Towels• Non-sterile Cloth Towels• Ioban• FenestratedDressings• Band-aids• Transparent (Tegaderm)• 4 X 4 Drain Sponges• 2 X 2 Drain Sponges• Abdominal pad (WetPruf• pad/ABD combine)• Stockinette, standard• Stockinette, impervious• Gauze non-sterile• Gauze rolls, sterile• Steri-stri

www.medshare.org

To Prevent This…

The Loadmaster

The Loadmaster

The Transporter

The Department of Health and Human Services has requested that NO medical personnel go to Haiti unless they are members of the State Medical Reserve Corps or are certified members of the ESAR-VHP program.

The situation is such that unless individuals are with one of these organized groups, they will be at risk, and in need of supervision and supplies that cannot be provided. At present, other than those in the above groups, we have been requested not to go…..

GME’s Interpretation= NO RESIDENTS TO GO

TEAM A January 26th -Feb 2nd

• Shane Woolf, MD

• Megan Fulton, PA

• Susan Wimberly, RN

• Jennifer Haughney, RN

• Jean Hilliard, Pharm Student

Supply and Demand

Gary

Few Upper Extremity Injuries

Physical Therapy

Hypergranulation

Amputation Equipment Lacking

Florica

Florica

Lupin and Megan

Who’s In Control?

US Marines

Uruguay UN Team

Red Cross

MEBSH: Missionary Evangelical Baptists of Southern Haiti

ACWR: Apostolic Christian World Relief

MTI: Missions Training International

LMM: Lumiere Medical Ministries

OMS: One Mission Society (Jackson, Miss Team)

TEAM B February 2nd – February 11th

• Lee Cross, MD (Atlanta)

• David Jaskwich, MD (Charleston)

• Chris Keto, CRNA (MUSC)

• HannekeTenhultzer, RN (MUSC)

• Susan Wimberely, RN (MUSC) (Extended Tour)

TEAM B

Hospital Environment

Sterility Issues?

Hospital Equipment

Anaesthesia

• Limited Gas• Mostly Spinals with Marcaine• Limited Monitoring• No AEDS or Defibs

Radiology Prior To PACSPoidvainErisias- Radiology Tech

* Oldest Employee at Hospital Lumiere @ 75

EMR

Doctor’s Lounge

Rolling plaster

Closed Fasciotomies

Wound rounds by digital photography

Femoral Fractures

Some fractures were complex

Retrograde Nails

ORIF in Austere Settings

• Due to the nature of wounds and the environment, internal fixation is generally discouraged in battlefield settings.Concerns have been raised regarding anecdotally high infection rates in fractures treated with intramedullary nailing.

•Operation Iraq Freedom (OIE) and Operation Enduring Freedom (OEF) experiences showed that 50% of open upper extremity fractures were culture positive on admission to Bethesda

Outcomes of Internal Fixation in a Combat Environment

50 Cases Reviewed in which primary ORIF was utilized in selected patients.

The majority were hip (28%), forearm (28%), and ankle fractures (20%)

Sixteen (32%) were open

NO femoral fractures were listed

1 case (2%) eventually had infection

Ten (20%) required additional revision

Conclusion: Judicious use of internal fixation could be used in a combat setting without an increased risk of infection

Stinner et al, JSOA, 2010

External fixation conversion to IM nail

• Scalea et al.’s retrospective chart review:– Initial ex fix placement vs. primary IMN of the

femur• Conclusions

– Allowed for rapid correction, negligible blood loss, conversion to IMN when patient is stabilized, with minimal complications

– The benefits of DCO is greatest in patients with severe head trauma or pulmonary injury

Scalea TM, Boswell SA, Scott JD, Mitchell KA, Kramer ME, Pollak AN. External fixation as a bridge to intramedullary nailing for patients with multiple injuries and with femur fractures: Damage control orthopedics. J Trauma. 2000;48:613-23.

Pape H-C, Auf'm'Kolk M, Paffrath T, Regel G, Sturm J, Tscherne H. Primary intramedullary femur fixation in multiple trauma patients with associated lung contusion--a cause of posttraumatic ards? J Trauma. 1993;34:540-8.

Derotational Boot

TEAM C Feb 9th- Feb 15th

• Keith Merrill, MD

• Greg Colbath, MD

• Harris Slone, MD

Chart Review with Merrill

Preop planning

Bilateral Ex- Fix with exposed tendon

Bedside Wound Care (Steven Widmer 1st Year Resident Ohio)

OR 1st Day

No MesherPiecutting Graft

Frees Up Wound Vac for Bethlie

Care and Feeding of an Ex-fix

Granulation

Ex-Fix Revision

Henry Louis- Prequake Victim

•Acetabular Fracture• Femur Fx (s/p IM nail) • Proximal Tibia Fx (nonunion)

• Recent Femoral Disarticulation

Haitian Alarm Clocks

Kervans with compartment syndrome

The Bonecrushers

TravelingSquad

Dim Sum Wound Care Cart

Spanning Ex-Fix

Washouts

Shirley Peltrop

• Near Death From Sepsis

• B/L Fasciotomies

• Right Side eventually closed

• Left Side Bridged Wound Vac

“Be prepared to step out of your skill set”- Dr. Reed

Baby Valentina

TEAM D

• Langdon Harstock, MD

• Harry Demos, MD

• Richard Hawkins, MD (Spatanburg)

• Zeke Walton, MD

• Phil Botham, RN (Wound Care)

• Phil Tolman, PA (On Loan from Dr. Merrill)

Bahamas Habitat

Just in time for Night Rounds

Kids in A Candy Store

Pre Op Planning

Synthes Battlefield Ex-Fix

Midshaft Tibia Fracture

• Ex-Fix conversion to

• IM Nail

• Difficulty passing wire

• Ultimately ORIF

• Extended ABX course

ER Clinic/Internet Cafe

Ponsetti Clinic

Comments from Dr Bernard Nau

• 89% of the injuries were orthopedic trauma with lower limb fracture being the most common injury.

• Infected open fractures, lower limb wound infection with a different distribution of pathogens isolated than before the earthquake and a high rate of isolated drug resistant bacteria will be a challenge. These changes in the spectrum of pathogens and in the drug resistance pathogens isolated following this earthquake will provide a basis for the long term treatment.

• Those children will undergo many surgeries for osteomyelitis care, flaps, skin grafts... so a good pain management program will be very helpful.

• It should be a NATION WIDE PLAN and we should propose to have a medical team specialized in shock trauma treatment for adult & children

Disability Legacy of the Haitian Earthquake

• Large number of children suffered debilitating injuries, particularly affecting arms and legs –many required amputations

• Nearly 50 per cent of Haiti's population is under the age of 18

• Shriner’s is considering prosthetics in Haiti and transfer of many patients

• 6,000-8,000 persons with amputations

Annals of Internal Medecine. March 2010

Second Phase Relief• Postoperative care and follow-up of patients

who have undergone surgery

• Rehabilitative services for people with disabilities

• Prosthetic limbs for amputees

• Provide primary healthcare services to the displaced and control epidemic disease

– Tetanus Cholera Malaria

– Typhoid Dysentery Food borne

Long Range

• Grass root efforts begun now are need to rebuild a fragmented health care delivery system plagued by limited education and corruption

• Disaster relief can be administered successfully in small, rural areas like Bonne Finn and HopitalLumiere.

• These locations could network as receiving hospitals for Haitians requiring acute medical care in categories defined by Haitian physician levels of expertise.

Rehab at CitiLumiere

June Hanks

What Can Team E Expect?

• Rain

• Opened Commercial Traffic

• Stabilized Wounds

• Many Revisions

• Delayed Presentations

• Maybe even larger humanitarian needs

• John McFadden, MD

• Noah Weiss, MD

• Eric Angermeier, MD

• PT (2)

• Anaesthesia

• Nurses (2)

Latest Update from Rudolph• Over 600 trauma people since the quake treated at Hospital Lumiere

*300 admissions and 300 more seen in ER and out patient clinic department

• 300+ Surgical Procedures Performed

• 5 Deaths : septicemia with multiple open wound;3 patients post-op from late stage of sepsis and hemodynamic and hydro-electrolytic imbalanced, 1 case non traumatic.

• -30% of the patients had to undergo amputations secondary to crush injury complications with delayed compartment syndrome and limb necrosis.

• More risks of amputations for Naika Etienne and Paul Bethlie are of high concerns if advanced care are not available (transfer in USA is in good process for both of them)

• -95% of the skin grafts have taken.

• -95% success of the internal fixation of the femur fx (5 patients still inward).

• -95% success of the fasciotomies (with 2 patients still inward Shirley Peltrop and KervensDorvilier).

• -85% success of the Ex-Fix (12 patients still inward) would need further evaluation for long term bone fx healing r/o pseudarthosis or non union from chronic infections.

• Currently 40 Ortho patients : 15 new patients with tib/fib fx, pelvic fractures, t-spine and L-spine fx with lower ext paralysis with decubitusulcers,open hand fx,forearmosteomyelitis head trauma,...

Petitionville Golf Course-Now home to 50,000 tent displaced persons Sanitation Issues

Funeral Day

Reestablish Trade