419: Successes and Challenges of Trauma Care During the Haitian Earthquake

Abstract

Specific trauma patterns and causes of inhospital mortality after earthquake disasters have not been extensively studied. We present lessons learned during the Haitian earthquake of January 2010 including a triage model, injury summary and mortality patterns from a two-week experience at a district hospital in Haiti after the quake. This is an observational, descriptive study of injury patterns, and mortality of earthquake victims at St. Marc Hospital, a district hospital supported by Partners in Health located 40 miles north of the quake epicenter. We developed a victim census in Microsoft Excel to record our observations, patient lists and outcomes. During clinical care, we established a triage system to identify high-risk patients requiring immediate operative care as described. Patients were re-triaged daily to match our patients changing conditions and new arrivals. On day 4 post-earthquake, our inpatient census included 142 major traumatic diagnoses, including 42 open fractures, 17 major open wounds, 11 neglected compartment syndromes, 22 closed femoral fractures (5 pediatric), 13 pelvic ring injuries, 2 quadriplegics and 4 paraplegics, 22 closed extremity fractures, 2 patients with multiple rib fractures, 1 undiagnosed pneumothorax, 3 contusions with burns, 2 acetabular fractures, 4 head injuries (1 with ruptured globe), 2 abdominal injuries and many with significant soft tissue injuries. Roles for emergency physicians and nurses included triage and stabilization of inpatients and new arrivals, surgical ward patient care including complex wound care and management of metabolic issues, coordination of incoming volunteers and communications/evacuations. In 14 days, we saw hundreds of outpatients in the emergency area, and our surgeons performed 216 earthquake-related procedures. There were 12 inpatient earthquake-associated deaths (Mortality rate =8%). Eleven patients with open fractures left against medical advice to seek other medical opinions when amputation was discussed as the treatment of choice. Of the 11 amputations, all but 1 (massive PE, 5 days after hip disarticulation) survived without sepsis. The 11 closed compartment syndromes were hydrated and observed. Two, both with compartment syndrome affecting the buttock, thigh, and leg died of rhabdomyolysis, but all the others survived with preserved limbs. Earthquake victims overwhelmingly suffer from orthopedic and crush injuries, severe wounds, and metabolic issues related to rhabdomyolysis/dehydration. Causes of inhospital death in this type of setting include pulmonary embolism, rhabdomyolysis, sepsis, and respiratory failure. Unanticipated challenges included coordination of multiple unaffiliated medical volunteers arriving daily, consequences of lack of cold chain for tetanus vaccines, lack of heparin as an essential medicine for victims, and cultural challenges including attitude toward amputation, immobilization, and foreign staff presence. We hope our observations may aid in preparation of future teams responding to earthquake disasters.