surgical teams serve in haiti

Operating in Haiti: An orthopedic trauma surgeon’s story

Malcolm Smith, MD, an orthopedic trauma surgeon at Massachusetts General Hospital, spoke with OR Manager clinical editor, Judy Mathias, RN, MA, about his 2-week trip to Haiti in January 2010.

Q. Please tell us what you saw and how you had to be flexible and help these patients.
The main thing was that when we got there, there was virtually no facility available. We were initially taken to St Marc, probably about 60 to 70 miles out from Port-au-Prince. A lot of patients had been taken there with private transport. One of the patients told me that they christened the bus the Obama because it’d come and rescued them.

So there was a whole pile of people. I can’t imagine how awful this trip must have been. They were just picked up from wherever they were in Port-au-Prince and put on this bus and taken along the only paved road in the country to St Marc, which has a little hospital run by the government.

Q. Tell me about the facilities you found.
When we arrived, we discovered the operating rooms were not functional. The recovery room was full of crates. They did some c-sections under spinal anesthesia.

They had a little autoclave you could only get a small package of instruments in. They worked without a scrub nurse, just with an anesthesia tech who put a spinal in the patients. There were 2 small operating rooms. Neither of them had proper operating lights, just normal bulbs in the ceiling. The only way you could really operate was in daylight. If it got too late in the evening, we kept headlights on.

At first, we thought the place wasn’t usable. We went back to the place where we were going to stay, dropped off our bags, and said, we’ve got to go back and try. So we went and had a look around. We counted up nearly 175 patients, all with major injuries. And they’re all lying on the floor on thin mattresses. There were no beds; some were lying on doors. There were no sinks in the wards, no toilet facilities. Patients had been 2 to 5 days with the same dressings on. A few had IVs running, and a couple had antibiotics in the IVs.

Q. What did you decide to do?
We went around and split the rooms between us, went around, and tried to assess the patients. Then we met up and made treatment priorities. We asked people in the operating room to clean it a bit. We managed to get one of the anesthesia machines working.

We found the recovery room was full of packing crates. We got great help from the locals, who came in and pulled the crates apart, and we found a recovery room gurney and a brand new operating room table, two pro packs— packed away. Nobody knew they were there. So we got a recovery room working.

We did 6 or 7 patients the first day, some major debridements, and tried to concentrate on removing dead tissue first out of the amputations or wound debridement.

We kept a data base and ended up with 143 patients in the data base: 42 open fractures, 17 major open wounds, 12 neglected compartment syndromes, 22 femur fractures, 13 pelvic rings; 4 paraplegics; 2 quadriplegics, 13 closed tibias, 3 ankle or foot fractures, 6 other fractures, 2 patients with bad chest injuries, 1 misdiagnosed pneumothorax, 3 with major contusions or burns, 2 acetabular fractures, 4 head injuries, 3 ruptured eyes, 2 abdominal injuries, and other injuries like bruises and grazes.

In 14 days, we performed 260 earthquake-related procedures, 136 in the operating room and 80 complex dressing changes on the wards under anesthesia. Eventually, we had enough assistance mainly from a second team from California that we could walk on the wards and do dressing changes there, which made things a lot more comfortable.

We had 12 earthquake-related deaths. Of 11 people we performed amputations on, we only lost 1, and that was a massive pulmonary embolism 5 days after surgery. When you got rid of the necrotic tissue, the patients didn’t die. Even though we did a lot of amputations and extensive debridements, only one of the patients died of sepsis after that and she was critically ill when she arrived.

Q. How did the patients cope with this?
They were all very stoic, amazing. They all had morphine immediately postoperatively, but after they got on the floor there wasn’t adequate monitoring for morphine, so they all had anti-inflammatories postoperatively. It’s not what we were used to, but they were very stoic and did extremely well.

Q. What do you see as the future health care needs there?
The whole medical system was completely destroyed. The medical school fell down and killed nearly all the medical students. The nursing school fell down and killed nearly all the nursing students. There is no cadre of training professionals to look after these people in the next few years because they’re all gone.

I saw a report yesterday looking at probably 4,000 primary amputees. We did 8 or 9 injuries for each amputation, so if you take that as a standard, that takes you to somewhere in the order of about 40,000 major fractures fixed, or not fixed. There’s probably at least a 20% complication rate. So you’re looking at perhaps 10,000 needing repeated operations for the next year.

Q. Do you think you will be going back?
We’re in the process of trying to organize a long-term association with Partners in Health for our service. One of my partners is there now in St. Marc.

Q. Did you have a most memorable patient?
There were 2 girls, a 12-year-old and a 16-year-old. The 12-year-old came in on the second day, just walked into the emergency room, and somebody asked if we’d look at this girl’s hand. Her hand was just pulp. She sat there with her hand in the air and a bandage on it. I’ve never seen anything like it. It was the worst destroyed limb I’ve ever seen. No crying, never a word.

The first patient we were able to put an external fixator on was a 12-year-old boy. We had a spinal in, and he actually sang hymns through the whole procedure. He knew he was going to come out with his leg on, and he was so pleased.
. . .

The best thing was when we could start to do things. When we put the first external fixator on him and then the second child and the third; we put 4 or 5 on the first day. All of a sudden, all of the patients were going back to the floor with their legs on, and their fractures fixed. External fixators aren’t the best things in the world, but they worked. And all of a sudden, the people were looking happy in the wards. The smell was starting to go, the infection, and the flies were starting to go because the dead tissue wasn’t there anymore, and the corner was turned. Then the helicopters started to land and the sicker patients started to get taken away. So, all of the sudden, it was game on, and were able to do what we do and actually fix things.

Most of us are hoping to go back as a group in early May, hopefully to the same place, but it depends on the need. We’ve got a good group of people. It’s lovely to meet people who are so well-meaning and who are in that situation to just do things and get things working.