Sunday, February 14, 2010

Haiti: Follow-up, My Medical Experience and Future Needs.

I felt I should summarize what I did from a medical point of view and some new principles I notices. Also I will talk about the future needs.

I was with a group of 13 physicians and nurses. The first day we split up and eight of us went to CDTI Hospital (one of only two hospitals in Port Au Prince{PAP} still standing) and joined the American team of about 25 already there. The other 5 went to an orphanage 20 minutes away. The hospital had severe damage to the patient room section so all the patients were kept in the courtyard in eight(8) tents set up by the French. The Americans were responsible for four(4) and the French the rest. The Americans were there from 7:30 till 8:30 each day, and we left 3 military medics there over night. The French were there 9AM to 4:30PM and left no one to take care of their patients at night. If one of their patients had a problem hopefully their family would get one of the medics and they could handle it, otherwise the patient died as happened. 3-400 patients came to be evaluated at the hospital each day. I was consulted on about a dozen each day.

The surgeries I performed or assisted in included:
  • Four reverse solius flaps (assisted 2 and performed 2)
  • two gastrocnemius flaps
  • Above elbow arm amputation
  • Ten (10) dressings under anesthesia (ketamine/versed sedation)
  • Eight (8) Drainage of abscess and/or debridement of wounds (bone.muscle and skin).
I saw the first patient I ever witnessed die of Tetanus. After that I gave every patient with an open wound a tetanus vaccine.

We had two patients who were anemic, one with HCT=17 and another with HCT=21. I wanted to transfer the patient with 17 to a facility when I found out we could not get blood to our facility to do the transfusion. I was told because of the limited resources we could not transfer the patients till their HCT=12 or HGB=4. This, by the way, is the point when 50% of patients will die. I was told to stop doing blood counts since we most likely couldn't do anything about it. This was one of the hardest things I have ever done in medicine (except maybe the next story).

I was the lead physician of a trauma patient that came in. He was a fifty something man who had been struck by a truck. The police brought him in a police car and dropped him on the curb and drove off without waiting or telling us anything. The man was in coma and had obvious abdominal trauma. In the states he would have been brought immediately to the operating room for an exploration. We had no anesthesia personnel, no labs, no x-ray. He had no blood pressure until we resuscitated him with three liters of fluids. We called the director of the hospital and asked her to arrange transport. She told us there was no transport and to put him in the courtyard on a stretcher and if he is alive in the AM we will then deal with it. I could not accept this. So I told the medics to pump fluid into him to keep his blood pressure over 100 and his urine output over 50 cc per hour. With hard work they kept him alive over night and had to give an additional 7 liters of fluids. He had a liver injury and a fractured pelvis. We transfered him to the French Hospital ship. We found out he had survived.

I wrote about baby Noah multiple times.

Privacy: There was none. Foleys were put in in an open co-ed tent with the other patients and their families looking on. Patients washed themselves out in the open.

There were many patients, I took care of 4 of them (amputating the arm of one and one other had the HCT=17), who had closed crush injuries of their arms. They came to the Hospital 7-14 days after the earthquake with a compartment syndrome. This is when from a crush injury the muscle swells to the point that the nerves and muscle in the limb dies. the skin and bone survive. If you see the patient within hours of the injury (usually less then 6) opening the arm and releasing the pressure can save function in the arm. Opening the arm at 7-14 days has no chance of saving function. It only exposes dead tissue to infection and gives a massive surface that will slowly loss blood (thus the low HCT). If they had not done fasciotomy(opening the arm) the patient would have ultimately needed an amputation but could have had a functional id forearm amputation instead of being condemned to an above elbow amputation.

The temperature was 85-94 degrees every day with 70-85% humidity. This is the definition of an incubator to culture bacteria. Except for the operating room there was no clean areas of patient care. As a matter of fact the patients were housed in an open field with every bacteria blowing around. Every open wound was contaminated, most with pseudomonus. The problem wasn't that we didn't have the antibiotics, we did. It was that with all those open fracture. Open fractures are being treated by putting on an ex-fixiture (ex-fix) to stabilize the bone. The problem is that the area of the fracture with the open skin wound has poor circulation so the antibiotics do not get there. To over come this I started using Daikin's solution. This is a 0ne percent clorax solution. I would drip it at 10 cc's per hour into the wound and the next day there would be no infection.

It was felt that a large number of early amputations may have been unneeded. Therefor before we left there was a policy in place that two American and one Haitian surgeons need to concur on all needs for amputation.

Every patient coming to the hospital was dehydrated and malnourished. I will talk about food and water in a separate post. It is just that from a medical point of view they started behind.

The obvious biggest need is food and water. From a medical perspective the care of the 200-300,000 open fractures is the major medical work that will be done over the next 3-6 weeks. This is phase two of these open fractures, phase one was applying the ex-fix and doing the early amputations. The third phase will be late amputations over the next two months. all of these 200-300,000 open fractures are at risk of this. This could double the number of amputations. Phase four is rehab. There will need to be multiple centers for rehab centers. There will need for 400-500,000 artificial limbs and the people to fit them and the people to do the rehab. I'm currently working to help start this effort. Also there are some inexpensive prostectics used in the third world. I am planning on contacting them.

Finally the rainy season will begin in one to two weeks. This means that almost every day there will be a one-two hour deluge delivering one to one and a half (1-1.5 inch) of rain. Almost every drainage ditch is filled with rubble. Even with them open many streets were turned into rivers in past rainy season. This year with almost no functional drainage ditches most streets will become rivers. With almost 1,000,000 homeless and living in tents on the streets, 200,000 buried inadequately in mass graves and 100-150,000 still under the rubble, a public health crisis on unimaginable proportion is on it's way. I cannot even imagine how to prepare for this or how when it happens it will be handled but I plan to return in the middle of the rainy season so I will be able to report on it.

cdti Hospital, Haiti, earthquake, disaster, Dr. Alan Koslow, french, patients, tetanus, solius flap, gastracnemeus flap, amputation, anesthesia, transfusion, trauma, fasciotomy, pseudomonus, daikin's, rainy season

36 comments:

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  7. 當一個人內心能容納兩樣相互衝突的東西,這個人便開始變得有價值了。............................................................

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    ReplyDelete
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