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Disaster triage after the Haitian earthquake
Injury, Int. J. Care Injured 43 (2012) 1811–1815
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Disaster triage after the Haitian earthquake R.M. Smith a,*, G.S.M. Dyer b, K. Antonangeli a, N. Arredondo e, H. Bedlion b, A. Dalal a, G.M. Deveny a, G. Joseph f, D. Lauria a, S.H. Lockhart i, S. Lucien b, S. Marsh g,h, S.O. Rogers b, H. Salzarulo g,h, S. Shah d, R.J. Toussaint a, J. Wagoner c a
Massachusetts General Hospital, Boston, MA, United States Brigham and Women’s Hospital, Boston, MA, United States Beth Israel Deaconess Medical Center, Boston, MA, United States d Rhode Island Hospital, Providence, RI, United States e Lakeland Regional Medical Center, FL, United States f Albert Einstein Hospital, NY, United States g Blue Ridge Orthopedics, Seneca, SC, United States h Partners In Health, Boston, MA, United States i Sutter Health, Walnut Creek, CA, United States b c
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 18 July 2011
In the aftermath of the devastating Haitian earthquake, we became the primary relief service for a large group of severely injured earthquake victims. Finding ourselves virtually isolated with extremely limited facilities and a group of critically injured patients whose needs vastly outstripped the available resources we employed a disaster triage system to organize their clinical care. This report describes the specific injury profile of this group of patients, their clinical course, and the management philosophy that we employed. It provides useful lessons for similar situations in the future. ß 2011 Elsevier Ltd. All rights reserved.
Keywords: Disaster triage Compartment syndrome Sepsis Haiti earthquake
Introduction On January 12, 2010, Haiti was hit by a devastating 7.0 earthquake. It is estimated that over 300,000 were killed, and many more significantly injured. Arriving four days after the earthquake, our team of 16, was assigned by our sponsoring charity (Partners In Health) to Hospital St. Nicholas, in St. Marc, a public hospital 80 miles outside Port au Prince, becoming the primary relief service to the area. There, we found a large group of severely injured patients who had been transported from the earthquake zone in the hope of finding functioning medical facilities and safety. The hospital was small and partly disused. The ‘‘wards’’ were essentially bare rooms without basic necessities such as sinks, toilets, or functioning nursing stations. Very few local staff were present, and the victims had received minimal medical treatment. The patients were lying on the floor on thin mattresses or blankets (Fig. 1), all with four day old, untreated major injuries. These included open fractures, established compartment syndromes, spinal fractures with paraplegia, multiple dirty, open wounds, and many closed fractures.
* Corresponding author at: Department of Orthopaedic Surgery, YAW3600C, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA. Tel.: +1 6177262794; fax: +1 6177268214. E-mail address: [email protected] (R.M. Smith). 0020–1383/$ – see front matter ß 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2011.07.015
Several patients with spinal cord injuries were lying on doors and one on an ironing board. All had already developed pressure ulcers. Although there were two operating rooms, both were unsanitary, and there was no functioning anaesthetic machine. There were two simple autoclaves but both were too small for a standard set of instruments or implants. The ‘‘recovery room’’ and adjacent corridor were unused and full of crates and broken boxes (Fig. 2). There was a single X-ray room able to take basic x-rays after which the wet films were hung up to dry in the sun (Fig. 3); there was no facility for intra-operative X-rays. There were no other functioning local services and no available backup. Organization and triage With the help of local volunteers, one operating room was made functional within a few hours and limited clinical supplies found. As reported from similar events1,2 (Yang, Salimi), the surviving patients had mainly major musculoskeletal injuries (Table 1). Any major head, chest, or abdominal injuries had already proven fatal. There were a large number of critically injured patients, mainly with impending or established sepsis due to neglected wounds. Given the crisis of need and poor facilities, we developed and utilized a triage system (Fig. 4) to prioritize treatment and to maximize the use of scarce resources. The next day, our arrival was announced on the local radio and more patients presented,
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Fig. 3. Wet films hung up to dry in the sun outside the basic X-ray room. Fig. 1. Patients were lying on the floor on thin mattresses or blankets.
including 2 who were in septic shock after initial treatment elsewhere. These daily new arrivals and the constant fluctuation in the condition of patients in the hospital led to a constant need to reassess our surgical plans and each individual’s triage category. Triage category’s A, B, C and D are self explanatory with initial priority being given to septic patients. Category ‘‘E’’ was established for patients we hoped to evacuate when able. However, our first helicopter evacuation did not occur until 11 days after the earthquake. Whilst clinically stable, these patients were observed and hydrated. Isolation and lack of contact with any potential receiving centre made triage for transfer very difficult.
Table 1 Diagnostic data from 142 earthquake victims with 150 major diagnoses. Diagnostic data 42 open fractures 17 major open wounds 11 neglected compartment syndromes 22 closed femoral fractures (5 paediatric) 13 pelvic ring injuries (10 mechanically unstable) 4 paraplegics, 2 quadriplegics, 2 acetabular fractures 13 closed tibial fx, 3 other lower limb fx, 6 closed upper limb fx 2 multiple rib fractures, 1 undiagnosed pneumothorax 4 head injuries (including 1 ruptured globe) 3 contusion/burns, 2 abdominal injuries and many major closed soft tissue injuries
The patients placed in Category ‘‘F’’ were an ethical dilemma to be expected in this scenario but caused the most anguish amongst us. These were patients who would have been the highest priority for care in other circumstances but, in this situation, had major problems that were beyond our ability to treat or whose treatment would be too resource dependent. We considered that these individual’s clinical condition was such that beginning operative management was likely to produce an intensive care dependent patient that would involve the use of our only ventilator (the anaesthetic machine) and prevent us treating other patients. This is perhaps the most difficult decision in clinical medicine. The care of these patients would be the highest priority in a normal clinical environment but, in the disaster setting, is too costly in time and/or resources. Although an established principle, it was a new experience to all of our team. Whilst all agreed with its
Triage scheme
Fig. 2. The ‘‘recovery room’’ and adjacent corridor were unused and full of crates and broken boxes.
A
Surgery today to save life
B
Surgery today to save limb
C
Surgery as soon as possible for wounds
D
Surgery when possible for closed fracture
E
Evacuate when able
F
Observe
Fig. 4. Triage system used.
R.M. Smith et al. / Injury, Int. J. Care Injured 43 (2012) 1811–1815
implications, which patients to include and how long to maintain the policy was constantly discussed. We decided that we should maintain hydration, use antibiotics, give what pain control we could, and provide nursing care to those who were triaged not to receive surgical treatment. This way we were able to provide compassionate care without threatening the wellbeing of those with a potential to survive. The patients included in this group included all the spinal injuries, all the pelvic fractures (including open injuries), a patient with established tetanus, those with the most severe sepsis, and the patients with closed compartment syndromes, two of whom developed renal failure due to rhabdomyolysis. Whilst many died, several of these patients survived with supportive care only. The importance of the triage system became apparent during our second week when our overall clinical situation was more under control. A three-week-old baby presented with severe respiratory distress and noticeable mild congenital defects. The baby received maximal treatment, including use of the anaesthetic machine and operating room, to provide ‘‘intensive care’’. We cancelled many surgeries that day before the child was transferred and, unfortunately, later died. Had this happened when the full disaster triage scheme was in place, many other salvageable patients would have suffered and possibly died due to the loss of resources, and the triage system would have failed.
Procedures and mortality Over two weeks, we performed 216 earthquake-related procedures: 136 major cases in the OR and 80 complex ‘‘dressing changes’’ on the ‘‘wards’’ under anaesthesia. The pattern of procedures performed and the effect of the triage system on selection for surgery is shown in Fig. 5. We performed 7 additional procedures due to other pathologies presenting de novo, and the operating room was used for multiple Caesarian sections. At the end of our first week, we were reinforced by a second international team of a similar size and were able to acquire additional anaesthetic drugs, monitors, and other supplies, such that we significantly increased our operative capacity and introduced a wound dressing team that decompressed the operating room by allowing dressing changes under monitored sedation on the wards. Clinical cohort Whilst many other patients were treated with more minor injuires, our final data base held complete data on 142 trauma patients with 147 major diagnoses as described in Table 1. Mortality There were 12 earthquake related deaths. These were due to tetanus1, sepsis2, presumed massive pulmonary embolism2,
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rhabdomyolysis associated with extensive compartment syndrome2, and respiratory failure with C4 quadriplegia. In addition, there were 2 peri-operative deaths and 2 patients who presented to the emergency department in extremis and died. All of the other patients survived. The policy of early triage for sepsis led to only 1 patient dying of sepsis after surgery. We noted 2 deaths that were probably due to massive pulmonary embolus. We had no access to DVT prophylaxis and found all the patients immobile at 5 days. We do not know our incidence of silent DVT. Specific conditions Wounds, open fractures, and sepsis The most common clinical problem was open wounds and infection. After 5 days, many patients had critical infections with obvious dead tissue following open crush injuries. These were triaged to group A, with the highest priority for surgical debridement, often requiring amputation. Whilst essential and life saving, the number of patients requiring amputation in this phase led to major problems as disability is poorly accepted in Haiti. Fearing amputation, several patients refused surgery, and some left the hospital despite knowing that the alternative was probably death; their outcome is unknown. An analysis of wounds and the risk of amputation or death was performed. Fisher’s exact test was used for categorical variables and Wilcoxon rank sum test was used for continuous variables. Of the 142 patients, we considered that 90 were at risk for amputation of an extremity. Of the 90 evaluable patients, 12 required amputations. There was no difference in demographics between the patients who needed amputation compared to those in whom limb salvage was possible. However, patients with signs of sepsis (n = 25) (p < .0001) or compartment syndrome on initial presentation (n = 29) (p = 0.012) were more likely to require amputation. Patients with any wounds were more likely to undergo amputation compared with patients without wounds (p = 0.004). There was no significant difference in the rate of amputation when comparing small and large wounds (p = 0.74). Signs of rhabdomyolysis (n = 3) (p = 0.005) and wounds that were sewn shut or casted dirty (n = 8) (p = 0.002) increased the patient’s risk of death. Clearly, open wounds with underlying dead tissue was the major problem. Two patients died of sepsis, diagnosed clinically with failing vital signs and a localized source of severe infection. All of the other patients at risk of major infections and septicemia survived. Some had persisting issues with local wound infection but not of systemic sepsis. After surgical debridement and/or amputation, only one patient died of sepsis. This experience emphasizes the time-honoured principles of early and aggressive surgical treatment of infected wounds and the critical need for adequate debridement of necrotic and infected muscle. Concerned about our lack of operative resources, we performed primary closure on our first few amputations done at a clean level well away from the injury. However, all became infected. Subsequently, we left amputations and major wounds open for delayed closure. Closed compartment syndromes
Fig. 5. Patterns of surgical treatment of earthquake-related procedures created by the Triage system.
We saw 11 patients with established closed compartment syndromes of one or more limbs. One was decompensating with an avascular limb and was triaged ‘‘A’’ for immediate amputation. All the others had viable limbs; the primary presenting feature was flaccid paralysis with diffuse localized swelling in a viable limb. There were no major complaints of ongoing pain; each limb was tense with distal neurological loss of both motor function and sensation. In several patients, more than one limb was involved. Given the time from injury and lack of open wounds, we made an
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elective decision not to perform late fasciotomies and risk contaminating the already compromised compartments. We triaged this group of patients to group ‘‘F’’ maintained hydration in an attempt to minimize renal damage secondary to rhabdomyolysis but accepted the other, late sequelae of compartment syndrome. About the 6th day after injury, 2 patients developed a rapid loss of renal function and clinical acidosis. Both had established compartment syndrome in multiple areas including the buttock, thigh, and lower leg and, in one, also the upper limb. No electrolyte assessment or dialysis was available; hydration and alkalinization were the only possible treatments. Both patients rapidly worsened, became acidotic, anuric, and died within 24 h. All of the other patients with compartment syndrome survived without clinically obvious systemic problems. At 2 weeks, problems with contracture were starting to be evident. We believe these patients would not have been well served by fasciotomy as this would have put them in the same category as our severe open wounds with dead muscle, many of whom required amputation. If contracture is a major problem, they will be best served by late surgical management. Spinal injuries Six patients had significant spinal injuries, all with complete cord lesions. 4 were paraplegic and 2 quadriplegic. All were triaged to group ‘‘F’’. One quadriplegic had a clinical level at C4, poor respiratory function, and died 4 weeks after injury. At three weeks, however, all the paraplegics looked healthy; their ulcers were healing and were gaining enough spinal stability to begin to sit up. The long term prognosis for a paraplegic in the developing world is very poor, and they were all subsequently transferred to Canada for advanced management. Closed fractures: major, moderate, and minor There were a large number of patients with closed fractures. These ranged from mechanically unstable major pelvic ring injuries and acetabular fractures to more simple closed lower limb fractures, such as mid-diaphyseal tibial fractures that could be treated with casting alone. The complex injuries were triaged to category ‘‘E’’ or ‘‘F’’ and hydrated and nursed until transfer became available. By that time, most of the mechanically unstable pelvic injuries were starting to feel more comfortable sitting and were healing enough that transfer for operative care would not add significant advantages and a non-operative care plan was continued. There were a large number of diaphyseal femoral fractures both in adults and children. All the children were treated with spica casts, a standard treatment, which yields predictably good results. Initially, the adults were triaged to group ‘‘D’’ and treated by splinting alone until there was a surgical capability for operative treatment. We treated many of these fractures with external fixators, which allow weightbearing for mobility and some joint motion. With no intraoperative radiographic monitoring available, all the external fixators had to be applied blind, using only the sound of the drill and resistance felt from the pin to assess the depth of pin penetration. Fracture reduction was assessed clinically. As some of these procedures were performed over 2 weeks from injury, early healing in a deformed position led to difficulties with reduction and, occasionally, an open procedure was required to obtain acceptable length and alignment. It was more than 2 weeks after the earthquake before the situation was under control enough for any definitive fixation of closed fractures to be performed. At this phase, we stabilized a small number of fractures operatively, all with good early results.
Complications Tetanus One patient presented in frank tetanus with an infected wound on her lower leg. Although available anti serum was given, she died within 48 hours awaiting transfer. Reports from other Haitian hospitals suggested that failure of cold storage of tetanus serum was a problem, and that even when treatment was given, the effectiveness was questionable. Thrombo-embolisum Two patients died from massive pulmonary embolism, the first, 5 days after a hip disarticulation for an open crush injury with sepsis and the second 11 days after a major pelvic fracture. No prophylactic measures against DVT were available and given the delay to treatment and number of injuries, even early mobilization was not possible. Fracture infection, union, and contracture Treating injuries late and in compromised situations is likely to lead to major long term complications. The poor general facilities and limited provision of equipment meant that fractures were treated in a way not optimal in our normal practice. Most importantly, the lack of an ability to use intramedullary nails was a major handicap. There was no image intensifier, no fracture table, and no facilities to sterilize anything larger than a few instruments. Indeed, there was no quality control of sterilization procedures creating some doubt about the use of implants. Whilst internal fixation was used when the gains were judged to outweigh the risks, external fixation was chosen as the primary mode of fracture stabilization for major lower limb diaphyseal fractures. This was extensively used throughout the country during the initial phase of surgical treatment as limited facilities were the rule rather than an exception. Using external fixators late and without the ability to provide close follow up is a problem. We expect that there will be a significant incidence of malunion, nonunion, and fracture infection that will need long term specialist surgical care. Given the number of injured patients, the scope of this problem will reach into the thousands of cases. Team structure and dynamics Working in a critical, stressful environment is difficult even for seasoned professionals. Our team’s experience ranged from considerable experience in major trauma management but no experience in the developing world to other members with significant experience in the developing world but not in disaster situations. The team proved to have close to an ideal skill and personality mix. Specifically, we had 2 orthopaedic trauma surgeons, a general trauma surgeon, 2 anesthesiologists, an internist (Haitian-American), and an ultrasound-trained emergency medicine physician. We had two operating room staff, two surgical nurses who became our recovery staff, and 3 other nurses, two of whom were Haitian-American and one with major experience in international medicine. We were joined by a Haitian-American orthopaedic resident and a nurse working for Partners In Health, who acted as our administrator. A number of additional volunteers arrived with a variety of skills for varying amounts of time, and we employed them as needed although organizing random volunteers proved to be a time consuming task. Most importantly, we were reinforced after a week by a team from California similar in size to ours who contributed considerably to our success. Whilst this balance of skills was functional, we needed
R.M. Smith et al. / Injury, Int. J. Care Injured 43 (2012) 1811–1815
a physical therapist and found our senior medical staff doing a lot of logistic work to keep our system running. The major surgical deficiency was in plastic surgery and the ability to provide simple skin grafting. Given the lack of serviceable medical equipment, a medical bio-engineer who could repair and maintain everything we normally take for granted would have been invaluable. The hospital was not functional at night, as there were regular power cuts and limited staff support. As we had too few staff to run two shifts, we all worked a single long shift, stopped working a few hours after sunset, and took a break to sleep and to maximize our ability to work through the next day. On two occasions, two of our staff remained awake to provide critical care for patients we did not feel were stable enough and were relieved of duties the next day. This policy worked well, maximized our efficiency, and made the effort sustainable in comparison to other groups that found the Haitian experience taxing and not sustainable. It proved essential for each person to be flexible and work outside of their normal roles as the situation demanded, there was no space for egos or predetermined authoritarian control. Our team became cohesive very quickly. All made invaluable contributions and the role of the Haitians cannot be underestimated. We greatly appreciated both those who travelled with us, and the local volunteers who worked in many roles and translated the language and the culture. The personal support within our team was hard to reproduce but essential. Our daily debriefing sessions and a ‘‘buddy system’’ for safety all helped to alleviate stress. We all had an experience outside anything we had seen before, but the support of the group made it rewarding and an enormous privilege to be involved with. Whilst counselling was widely offered on our return home, we all have preferred to look for support from those who had shared our experiences.
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we had performed fasciotomy over 4 days after injury, the most likely outcome would have been contamination of local necrotic muscle, sepsis, and amputation. We believe that avoiding late fasciotomy was the correct policy in this situation. The use of portable ultrasound in difficult situations has been noted before14,15, we found it invaluable to assess the abdomen in trauma (FAST), guide anaesthetic blocks, and diagnose right heart strain in pulmonary embolus amongst many other applications. The problem with communication and supply cannot be underestimated. In a situation where the basic infrastructure all failed, it is humbling to realize how little we can do without technological and logistic support. In this situation, clinicians need to be resourceful, improvise, and return to basic principles to be effective. There is no room for arrogance or an inability to work as part of a team. Most importantly, we learned the importance of team work and personal support. As a group, we found difficulty returning to our privileged home environment and have turned to each other regularly since our return. Several of us have been back to Haiti and are now actively exploring useful ways to continue to contribute to medical services there and throughout the developing world.
Conflict of interest statement All authors confirm that they have no financial or personal relationships with other people or organisations that could inappropriately influence (bias) this work. At the time of the events described the all authors provided medical care to the injured on a voluntary basis without payment. Sarah Marsh was an employee of the sponsoring charity, Partners In Health.
Discussion References Our experience was typical of an earthquake1–4 and dominated by those who had suffered major crush injuries but was unique in the isolation created by our specific situation and in the documentation of our clinical experience. The application of a disaster triage system is well described5–10 but rarely put into action, particularly in such extreme circumstances. We believe that it was the only way to organize the care of our patients and save lives and limbs. The system we developed is generic, independent of the specific clinical scenario, and applicable to any similar situation. The pattern of injuries we saw was similar to those described from previous earthquakes with musculoskeletal injury dominating the clinical picture in the early survivors1–4. Crush injury leads to local muscle necrosis either directly or by the development of compartment syndrome. Local wounds allow contamination of the compromised muscle and devastating infection is the result. Clearly, wide surgical debridement and often amputation is required. Our data confirm that the combination of wounds and necrotic muscle is predictive of the need for amputation and the other consequence of crush syndrome. It is humbling to be reminded that a neglected open fracture is still a potentially mortal injury. In contrast to other earthquakes where some medical infrastructure existed or survived11–13, there was no resource to usefully treat rhabdomyolysis. It was clearly the extent of the muscle damage that led to clinical evidence of rhabdomyolysis, renal failure, and death, as the patients with the most compartments involved died. Survival with a single, although seriously affected limb was the rule; however, without assessment of any chemical parameters, we are unaware of any less obvious systemic damage. Few have experience and little is written about observation of compartment syndrome when its diagnosis is delayed. Clearly, if
1. Yang C, Wang HY, Zhong HJ. The epidemiological analyses of trauma patients in Chongqing teaching hospitals following the Wenchuan earthquake. Injury 2009;40(5 (May)):488–92. Epub 2009 Mar 27. 2. Salimi J, Abbasi M, Khaji A. Analysis of 274 patients with extremity injuries caused by the Bam earthquake. Chin J Traumatol 2009;12(1 (February)):10–3. 3. Chunguang Z, Rigao C, Fuguo H, et al. Characteristics of crush syndrome caused by prolonged limb compression longer than 24 h in the Sichuan earthquake. Emerg Med J )2010;(June 17). Epub ahead of print. 4. Yasin MA, Malik SA, Nasreen G, Safdar CA. Experience with mass casualties in a subcontinent earthquake. Ulus Travma Acil Cerrahi Derg 2009;15(5 (September)):487–92. 5. Yasin Emami MJ, Tavakoli AR, Alemzadeh H, et al. Strategies in evaluation and management of Bam earthquake victims. Prehosp Disaster Med 2005;20(5 (September–October)):327–30. 6. Bostick NA, Subbarao I, Burkle Jr FM, Hsu EB, Armstrong JH, et al. Disaster triage systems for large-scale catastrophic events. Disaster Med Public Health Prep 2008;2(Suppl 1 (September)):S35–9. 7. Chen G, Lai W, Liu F, Mao Q, Tu F, Wen J, et al. The dragon strikes: lessons from the Wenchuan earthquake. Anesth Analg 2010;110(3 (March 1)):908–15. 8. Nie H, Tang SY, Lau WB, et al. Triage during the week of the Sichuan earthquake: a review of utilized patient triage, care, and disposition procedures. Injury 2010;41(7 (July)):1074–5. 9. Xiang B, Cheng W, Liu J, Huang L, Li Y, Liu L, et al. Triage of pediatric injuries after the 2008 Wen-Chuan earthquake in China. J Pediatr Surg 2009;44(12 (December)):2273–7. 10. Shi YK, Wang LL, Lin YD, Pei FX, Kang YM, et al. Challenges for rear hospital care of Wenchuan earthquake casualties: experience from West China Hospital. Chin J Traumatol 2010;13(3 (June 1)):131–6. 11. Li W, Qian J, Liu X. Management of severe crush injury in a front-line tent ICU after 2008 Wenchuan earthquake in China: an experience with 32 cases. Crit Care 2009;13(6):R178. Epub 2009 Nov 6. 12. Malinoski DJ, Slater MS, Mullins RJ. Crush injury and rhabdomyolysis. Crit Care Clin 2004;20(1 (January)):171–92. 13. Duman H, Kulahci Y, Sengezer M. Fasciotomy in crush injury resulting from prolonged pressure in an earthquake in Turkey. Emerg Med J 2003;20(3 (May)):251–2. 14. Nelson BP, Melnick ER, Li J. Portable ultrasound for remote environments. Part 1. Feasibility of field deployment. J Emerg Med )2010;(January 23). Epub ahead of print. 15. Dan D, Mingsong L, Jie T. Ultrasonographic applications after mass casualty incident caused by Wenchuan earthquake. J Trauma 2010;68(6 (June)):1417–20.
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Disaster triage after the Haitian earthquake R.M. Smith a,*, G.S.M. Dyer b, K. Antonangeli a, N. Arredondo e, H. Bedlion b, A. Dalal a, G.M. Deveny a, G. Joseph f, D. Lauria a, S.H. Lockhart i, S. Lucien b, S. Marsh g,h, S.O. Rogers b, H. Salzarulo g,h, S. Shah d, R.J. Toussaint a, J. Wagoner c a
Massachusetts General Hospital, Boston, MA, United States Brigham and Women’s Hospital, Boston, MA, United States Beth Israel Deaconess Medical Center, Boston, MA, United States d Rhode Island Hospital, Providence, RI, United States e Lakeland Regional Medical Center, FL, United States f Albert Einstein Hospital, NY, United States g Blue Ridge Orthopedics, Seneca, SC, United States h Partners In Health, Boston, MA, United States i Sutter Health, Walnut Creek, CA, United States b c
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 18 July 2011
In the aftermath of the devastating Haitian earthquake, we became the primary relief service for a large group of severely injured earthquake victims. Finding ourselves virtually isolated with extremely limited facilities and a group of critically injured patients whose needs vastly outstripped the available resources we employed a disaster triage system to organize their clinical care. This report describes the specific injury profile of this group of patients, their clinical course, and the management philosophy that we employed. It provides useful lessons for similar situations in the future. ß 2011 Elsevier Ltd. All rights reserved.
Keywords: Disaster triage Compartment syndrome Sepsis Haiti earthquake
Introduction On January 12, 2010, Haiti was hit by a devastating 7.0 earthquake. It is estimated that over 300,000 were killed, and many more significantly injured. Arriving four days after the earthquake, our team of 16, was assigned by our sponsoring charity (Partners In Health) to Hospital St. Nicholas, in St. Marc, a public hospital 80 miles outside Port au Prince, becoming the primary relief service to the area. There, we found a large group of severely injured patients who had been transported from the earthquake zone in the hope of finding functioning medical facilities and safety. The hospital was small and partly disused. The ‘‘wards’’ were essentially bare rooms without basic necessities such as sinks, toilets, or functioning nursing stations. Very few local staff were present, and the victims had received minimal medical treatment. The patients were lying on the floor on thin mattresses or blankets (Fig. 1), all with four day old, untreated major injuries. These included open fractures, established compartment syndromes, spinal fractures with paraplegia, multiple dirty, open wounds, and many closed fractures.
* Corresponding author at: Department of Orthopaedic Surgery, YAW3600C, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA. Tel.: +1 6177262794; fax: +1 6177268214. E-mail address: [email protected] (R.M. Smith). 0020–1383/$ – see front matter ß 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2011.07.015
Several patients with spinal cord injuries were lying on doors and one on an ironing board. All had already developed pressure ulcers. Although there were two operating rooms, both were unsanitary, and there was no functioning anaesthetic machine. There were two simple autoclaves but both were too small for a standard set of instruments or implants. The ‘‘recovery room’’ and adjacent corridor were unused and full of crates and broken boxes (Fig. 2). There was a single X-ray room able to take basic x-rays after which the wet films were hung up to dry in the sun (Fig. 3); there was no facility for intra-operative X-rays. There were no other functioning local services and no available backup. Organization and triage With the help of local volunteers, one operating room was made functional within a few hours and limited clinical supplies found. As reported from similar events1,2 (Yang, Salimi), the surviving patients had mainly major musculoskeletal injuries (Table 1). Any major head, chest, or abdominal injuries had already proven fatal. There were a large number of critically injured patients, mainly with impending or established sepsis due to neglected wounds. Given the crisis of need and poor facilities, we developed and utilized a triage system (Fig. 4) to prioritize treatment and to maximize the use of scarce resources. The next day, our arrival was announced on the local radio and more patients presented,
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Fig. 3. Wet films hung up to dry in the sun outside the basic X-ray room. Fig. 1. Patients were lying on the floor on thin mattresses or blankets.
including 2 who were in septic shock after initial treatment elsewhere. These daily new arrivals and the constant fluctuation in the condition of patients in the hospital led to a constant need to reassess our surgical plans and each individual’s triage category. Triage category’s A, B, C and D are self explanatory with initial priority being given to septic patients. Category ‘‘E’’ was established for patients we hoped to evacuate when able. However, our first helicopter evacuation did not occur until 11 days after the earthquake. Whilst clinically stable, these patients were observed and hydrated. Isolation and lack of contact with any potential receiving centre made triage for transfer very difficult.
Table 1 Diagnostic data from 142 earthquake victims with 150 major diagnoses. Diagnostic data 42 open fractures 17 major open wounds 11 neglected compartment syndromes 22 closed femoral fractures (5 paediatric) 13 pelvic ring injuries (10 mechanically unstable) 4 paraplegics, 2 quadriplegics, 2 acetabular fractures 13 closed tibial fx, 3 other lower limb fx, 6 closed upper limb fx 2 multiple rib fractures, 1 undiagnosed pneumothorax 4 head injuries (including 1 ruptured globe) 3 contusion/burns, 2 abdominal injuries and many major closed soft tissue injuries
The patients placed in Category ‘‘F’’ were an ethical dilemma to be expected in this scenario but caused the most anguish amongst us. These were patients who would have been the highest priority for care in other circumstances but, in this situation, had major problems that were beyond our ability to treat or whose treatment would be too resource dependent. We considered that these individual’s clinical condition was such that beginning operative management was likely to produce an intensive care dependent patient that would involve the use of our only ventilator (the anaesthetic machine) and prevent us treating other patients. This is perhaps the most difficult decision in clinical medicine. The care of these patients would be the highest priority in a normal clinical environment but, in the disaster setting, is too costly in time and/or resources. Although an established principle, it was a new experience to all of our team. Whilst all agreed with its
Triage scheme
Fig. 2. The ‘‘recovery room’’ and adjacent corridor were unused and full of crates and broken boxes.
A
Surgery today to save life
B
Surgery today to save limb
C
Surgery as soon as possible for wounds
D
Surgery when possible for closed fracture
E
Evacuate when able
F
Observe
Fig. 4. Triage system used.
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implications, which patients to include and how long to maintain the policy was constantly discussed. We decided that we should maintain hydration, use antibiotics, give what pain control we could, and provide nursing care to those who were triaged not to receive surgical treatment. This way we were able to provide compassionate care without threatening the wellbeing of those with a potential to survive. The patients included in this group included all the spinal injuries, all the pelvic fractures (including open injuries), a patient with established tetanus, those with the most severe sepsis, and the patients with closed compartment syndromes, two of whom developed renal failure due to rhabdomyolysis. Whilst many died, several of these patients survived with supportive care only. The importance of the triage system became apparent during our second week when our overall clinical situation was more under control. A three-week-old baby presented with severe respiratory distress and noticeable mild congenital defects. The baby received maximal treatment, including use of the anaesthetic machine and operating room, to provide ‘‘intensive care’’. We cancelled many surgeries that day before the child was transferred and, unfortunately, later died. Had this happened when the full disaster triage scheme was in place, many other salvageable patients would have suffered and possibly died due to the loss of resources, and the triage system would have failed.
Procedures and mortality Over two weeks, we performed 216 earthquake-related procedures: 136 major cases in the OR and 80 complex ‘‘dressing changes’’ on the ‘‘wards’’ under anaesthesia. The pattern of procedures performed and the effect of the triage system on selection for surgery is shown in Fig. 5. We performed 7 additional procedures due to other pathologies presenting de novo, and the operating room was used for multiple Caesarian sections. At the end of our first week, we were reinforced by a second international team of a similar size and were able to acquire additional anaesthetic drugs, monitors, and other supplies, such that we significantly increased our operative capacity and introduced a wound dressing team that decompressed the operating room by allowing dressing changes under monitored sedation on the wards. Clinical cohort Whilst many other patients were treated with more minor injuires, our final data base held complete data on 142 trauma patients with 147 major diagnoses as described in Table 1. Mortality There were 12 earthquake related deaths. These were due to tetanus1, sepsis2, presumed massive pulmonary embolism2,
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rhabdomyolysis associated with extensive compartment syndrome2, and respiratory failure with C4 quadriplegia. In addition, there were 2 peri-operative deaths and 2 patients who presented to the emergency department in extremis and died. All of the other patients survived. The policy of early triage for sepsis led to only 1 patient dying of sepsis after surgery. We noted 2 deaths that were probably due to massive pulmonary embolus. We had no access to DVT prophylaxis and found all the patients immobile at 5 days. We do not know our incidence of silent DVT. Specific conditions Wounds, open fractures, and sepsis The most common clinical problem was open wounds and infection. After 5 days, many patients had critical infections with obvious dead tissue following open crush injuries. These were triaged to group A, with the highest priority for surgical debridement, often requiring amputation. Whilst essential and life saving, the number of patients requiring amputation in this phase led to major problems as disability is poorly accepted in Haiti. Fearing amputation, several patients refused surgery, and some left the hospital despite knowing that the alternative was probably death; their outcome is unknown. An analysis of wounds and the risk of amputation or death was performed. Fisher’s exact test was used for categorical variables and Wilcoxon rank sum test was used for continuous variables. Of the 142 patients, we considered that 90 were at risk for amputation of an extremity. Of the 90 evaluable patients, 12 required amputations. There was no difference in demographics between the patients who needed amputation compared to those in whom limb salvage was possible. However, patients with signs of sepsis (n = 25) (p < .0001) or compartment syndrome on initial presentation (n = 29) (p = 0.012) were more likely to require amputation. Patients with any wounds were more likely to undergo amputation compared with patients without wounds (p = 0.004). There was no significant difference in the rate of amputation when comparing small and large wounds (p = 0.74). Signs of rhabdomyolysis (n = 3) (p = 0.005) and wounds that were sewn shut or casted dirty (n = 8) (p = 0.002) increased the patient’s risk of death. Clearly, open wounds with underlying dead tissue was the major problem. Two patients died of sepsis, diagnosed clinically with failing vital signs and a localized source of severe infection. All of the other patients at risk of major infections and septicemia survived. Some had persisting issues with local wound infection but not of systemic sepsis. After surgical debridement and/or amputation, only one patient died of sepsis. This experience emphasizes the time-honoured principles of early and aggressive surgical treatment of infected wounds and the critical need for adequate debridement of necrotic and infected muscle. Concerned about our lack of operative resources, we performed primary closure on our first few amputations done at a clean level well away from the injury. However, all became infected. Subsequently, we left amputations and major wounds open for delayed closure. Closed compartment syndromes
Fig. 5. Patterns of surgical treatment of earthquake-related procedures created by the Triage system.
We saw 11 patients with established closed compartment syndromes of one or more limbs. One was decompensating with an avascular limb and was triaged ‘‘A’’ for immediate amputation. All the others had viable limbs; the primary presenting feature was flaccid paralysis with diffuse localized swelling in a viable limb. There were no major complaints of ongoing pain; each limb was tense with distal neurological loss of both motor function and sensation. In several patients, more than one limb was involved. Given the time from injury and lack of open wounds, we made an
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elective decision not to perform late fasciotomies and risk contaminating the already compromised compartments. We triaged this group of patients to group ‘‘F’’ maintained hydration in an attempt to minimize renal damage secondary to rhabdomyolysis but accepted the other, late sequelae of compartment syndrome. About the 6th day after injury, 2 patients developed a rapid loss of renal function and clinical acidosis. Both had established compartment syndrome in multiple areas including the buttock, thigh, and lower leg and, in one, also the upper limb. No electrolyte assessment or dialysis was available; hydration and alkalinization were the only possible treatments. Both patients rapidly worsened, became acidotic, anuric, and died within 24 h. All of the other patients with compartment syndrome survived without clinically obvious systemic problems. At 2 weeks, problems with contracture were starting to be evident. We believe these patients would not have been well served by fasciotomy as this would have put them in the same category as our severe open wounds with dead muscle, many of whom required amputation. If contracture is a major problem, they will be best served by late surgical management. Spinal injuries Six patients had significant spinal injuries, all with complete cord lesions. 4 were paraplegic and 2 quadriplegic. All were triaged to group ‘‘F’’. One quadriplegic had a clinical level at C4, poor respiratory function, and died 4 weeks after injury. At three weeks, however, all the paraplegics looked healthy; their ulcers were healing and were gaining enough spinal stability to begin to sit up. The long term prognosis for a paraplegic in the developing world is very poor, and they were all subsequently transferred to Canada for advanced management. Closed fractures: major, moderate, and minor There were a large number of patients with closed fractures. These ranged from mechanically unstable major pelvic ring injuries and acetabular fractures to more simple closed lower limb fractures, such as mid-diaphyseal tibial fractures that could be treated with casting alone. The complex injuries were triaged to category ‘‘E’’ or ‘‘F’’ and hydrated and nursed until transfer became available. By that time, most of the mechanically unstable pelvic injuries were starting to feel more comfortable sitting and were healing enough that transfer for operative care would not add significant advantages and a non-operative care plan was continued. There were a large number of diaphyseal femoral fractures both in adults and children. All the children were treated with spica casts, a standard treatment, which yields predictably good results. Initially, the adults were triaged to group ‘‘D’’ and treated by splinting alone until there was a surgical capability for operative treatment. We treated many of these fractures with external fixators, which allow weightbearing for mobility and some joint motion. With no intraoperative radiographic monitoring available, all the external fixators had to be applied blind, using only the sound of the drill and resistance felt from the pin to assess the depth of pin penetration. Fracture reduction was assessed clinically. As some of these procedures were performed over 2 weeks from injury, early healing in a deformed position led to difficulties with reduction and, occasionally, an open procedure was required to obtain acceptable length and alignment. It was more than 2 weeks after the earthquake before the situation was under control enough for any definitive fixation of closed fractures to be performed. At this phase, we stabilized a small number of fractures operatively, all with good early results.
Complications Tetanus One patient presented in frank tetanus with an infected wound on her lower leg. Although available anti serum was given, she died within 48 hours awaiting transfer. Reports from other Haitian hospitals suggested that failure of cold storage of tetanus serum was a problem, and that even when treatment was given, the effectiveness was questionable. Thrombo-embolisum Two patients died from massive pulmonary embolism, the first, 5 days after a hip disarticulation for an open crush injury with sepsis and the second 11 days after a major pelvic fracture. No prophylactic measures against DVT were available and given the delay to treatment and number of injuries, even early mobilization was not possible. Fracture infection, union, and contracture Treating injuries late and in compromised situations is likely to lead to major long term complications. The poor general facilities and limited provision of equipment meant that fractures were treated in a way not optimal in our normal practice. Most importantly, the lack of an ability to use intramedullary nails was a major handicap. There was no image intensifier, no fracture table, and no facilities to sterilize anything larger than a few instruments. Indeed, there was no quality control of sterilization procedures creating some doubt about the use of implants. Whilst internal fixation was used when the gains were judged to outweigh the risks, external fixation was chosen as the primary mode of fracture stabilization for major lower limb diaphyseal fractures. This was extensively used throughout the country during the initial phase of surgical treatment as limited facilities were the rule rather than an exception. Using external fixators late and without the ability to provide close follow up is a problem. We expect that there will be a significant incidence of malunion, nonunion, and fracture infection that will need long term specialist surgical care. Given the number of injured patients, the scope of this problem will reach into the thousands of cases. Team structure and dynamics Working in a critical, stressful environment is difficult even for seasoned professionals. Our team’s experience ranged from considerable experience in major trauma management but no experience in the developing world to other members with significant experience in the developing world but not in disaster situations. The team proved to have close to an ideal skill and personality mix. Specifically, we had 2 orthopaedic trauma surgeons, a general trauma surgeon, 2 anesthesiologists, an internist (Haitian-American), and an ultrasound-trained emergency medicine physician. We had two operating room staff, two surgical nurses who became our recovery staff, and 3 other nurses, two of whom were Haitian-American and one with major experience in international medicine. We were joined by a Haitian-American orthopaedic resident and a nurse working for Partners In Health, who acted as our administrator. A number of additional volunteers arrived with a variety of skills for varying amounts of time, and we employed them as needed although organizing random volunteers proved to be a time consuming task. Most importantly, we were reinforced after a week by a team from California similar in size to ours who contributed considerably to our success. Whilst this balance of skills was functional, we needed
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a physical therapist and found our senior medical staff doing a lot of logistic work to keep our system running. The major surgical deficiency was in plastic surgery and the ability to provide simple skin grafting. Given the lack of serviceable medical equipment, a medical bio-engineer who could repair and maintain everything we normally take for granted would have been invaluable. The hospital was not functional at night, as there were regular power cuts and limited staff support. As we had too few staff to run two shifts, we all worked a single long shift, stopped working a few hours after sunset, and took a break to sleep and to maximize our ability to work through the next day. On two occasions, two of our staff remained awake to provide critical care for patients we did not feel were stable enough and were relieved of duties the next day. This policy worked well, maximized our efficiency, and made the effort sustainable in comparison to other groups that found the Haitian experience taxing and not sustainable. It proved essential for each person to be flexible and work outside of their normal roles as the situation demanded, there was no space for egos or predetermined authoritarian control. Our team became cohesive very quickly. All made invaluable contributions and the role of the Haitians cannot be underestimated. We greatly appreciated both those who travelled with us, and the local volunteers who worked in many roles and translated the language and the culture. The personal support within our team was hard to reproduce but essential. Our daily debriefing sessions and a ‘‘buddy system’’ for safety all helped to alleviate stress. We all had an experience outside anything we had seen before, but the support of the group made it rewarding and an enormous privilege to be involved with. Whilst counselling was widely offered on our return home, we all have preferred to look for support from those who had shared our experiences.
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we had performed fasciotomy over 4 days after injury, the most likely outcome would have been contamination of local necrotic muscle, sepsis, and amputation. We believe that avoiding late fasciotomy was the correct policy in this situation. The use of portable ultrasound in difficult situations has been noted before14,15, we found it invaluable to assess the abdomen in trauma (FAST), guide anaesthetic blocks, and diagnose right heart strain in pulmonary embolus amongst many other applications. The problem with communication and supply cannot be underestimated. In a situation where the basic infrastructure all failed, it is humbling to realize how little we can do without technological and logistic support. In this situation, clinicians need to be resourceful, improvise, and return to basic principles to be effective. There is no room for arrogance or an inability to work as part of a team. Most importantly, we learned the importance of team work and personal support. As a group, we found difficulty returning to our privileged home environment and have turned to each other regularly since our return. Several of us have been back to Haiti and are now actively exploring useful ways to continue to contribute to medical services there and throughout the developing world.
Conflict of interest statement All authors confirm that they have no financial or personal relationships with other people or organisations that could inappropriately influence (bias) this work. At the time of the events described the all authors provided medical care to the injured on a voluntary basis without payment. Sarah Marsh was an employee of the sponsoring charity, Partners In Health.
Discussion References Our experience was typical of an earthquake1–4 and dominated by those who had suffered major crush injuries but was unique in the isolation created by our specific situation and in the documentation of our clinical experience. The application of a disaster triage system is well described5–10 but rarely put into action, particularly in such extreme circumstances. We believe that it was the only way to organize the care of our patients and save lives and limbs. The system we developed is generic, independent of the specific clinical scenario, and applicable to any similar situation. The pattern of injuries we saw was similar to those described from previous earthquakes with musculoskeletal injury dominating the clinical picture in the early survivors1–4. Crush injury leads to local muscle necrosis either directly or by the development of compartment syndrome. Local wounds allow contamination of the compromised muscle and devastating infection is the result. Clearly, wide surgical debridement and often amputation is required. Our data confirm that the combination of wounds and necrotic muscle is predictive of the need for amputation and the other consequence of crush syndrome. It is humbling to be reminded that a neglected open fracture is still a potentially mortal injury. In contrast to other earthquakes where some medical infrastructure existed or survived11–13, there was no resource to usefully treat rhabdomyolysis. It was clearly the extent of the muscle damage that led to clinical evidence of rhabdomyolysis, renal failure, and death, as the patients with the most compartments involved died. Survival with a single, although seriously affected limb was the rule; however, without assessment of any chemical parameters, we are unaware of any less obvious systemic damage. Few have experience and little is written about observation of compartment syndrome when its diagnosis is delayed. Clearly, if
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