Reflections on the musc ortho haiti experience (final)

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? Why Haiti Chile - 8.8 Haiti – 7.0 Japan Islands - 7.0 China/Russia/Korea 6.9 Illinois – 3.8 Offshore N CA – 5.9 Papa NG – 6.2 Haiti – 5.9 Oklahoma – 4.0

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

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, Columbia Rick Reed MD, Charleston Mike Petrillo EMT, Hilton Head Aaron Kurtz, EMT Aaron Stephens, Water Missions International

Initial Assesment- Cite Lumiere

Initial Assesment- CitiLumiere

HopitalLumiere, Bonne Finn ,[object Object]

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,[object Object]

Acute Conditions days old open fractures and wounds crushed limbs (spines) blood loss severe dehydration, traumatic amputation, infection, delayed compartment, unstable fractures

Walking Wounded Casting for stable fractures Splinting limbs and pain relief 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”

1st Team Lessons Learned ,[object Object]

Use broad spectrum antibiotics

Use Tetanus toxoid even after injury ,[object Object]

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.

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

What to take Surgical instruments – sterile Cydex or sterilizers IV fluids – extra for irrigation Pain medication – local, regional, oral Antibiotics – IV and oral Bandages, betadine, gloves Casting supplies and splints Must travel with you or it will be “diverted” Must Haves balanced with “Oughta” Haves Leave Behinds

Medshare Supplies Drapes Impervious General Small Drapes Paper Towels Non-sterile Cloth Towels Ioban Fenestrated Dressings 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 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 www.medshare.org

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

MEBSH: Missionary Evangelical Baptists of Southern HaitiACWR: Apostolic Christian World ReliefMTI: Missions Training International LMM: Lumiere Medical MinistriesOMS: 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)

No AEDS or Defibs,[object Object]

Wound rounds by digital photography

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 revisionConclusion: 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.

TEAM C Feb 9th- Feb 15th Keith Merrill, MD Greg Colbath, MD Harris Slone, MD

Bilateral Ex- Fix with exposed tendon

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

Frees Up Wound Vac for Bethlie

Henry Louis- Prequake Victim ,[object Object]

Recent Femoral Disarticulation,[object Object]

Kervans with compartment syndrome

The BonecrushersTravelingSquad

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

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)

Midshaft Tibia Fracture Ex-Fix conversion to IM Nail Difficulty passing wire Ultimately ORIF Extended ABX course

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.

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

Reflections on the musc ortho haiti experience (final)

Recomendados

Recomendados

Más contenido relacionado

La actualidad más candente

La actualidad más candente (20)

Destacado

Destacado (9)

Similar a Reflections on the musc ortho haiti experience (final)

Similar a Reflections on the musc ortho haiti experience (final) (20)

Reflections on the musc ortho haiti experience (final)