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Surgeons’ Dispatch from Cange, Haiti

The roosters were curiously quiet. As daily aftershocks continuedto rock Haiti, the usual chatter of animals in this rural clinicin Cange was replaced by the roar of cars and ambulances rushingin from Port-au-Prince. With most of the hospitals in the capitalcity devastated by the January 12 earthquake, the once-remotehospital that was set up to serve the rural poor had becomea destination of choice for people injured in the capital.

Thanks to the work of Boston-based Partners in Health (PIH)and its Haitian sister organization, Zanmi Lasante (ZL), medicalcare in Haiti has improved over the past 25 years. The Cangefree clinic, which is 58 km from Port-au-Prince, opened in themid-1980s, originally focused on AIDS but has since evolvedinto a comprehensive hospital complex, which is now linked toa network of 10 hospitals and clinics in the region. An operatingroom was added in 1996, and surgeons from around the world beganworking with Haitian surgeons to develop surgical care, piggybackingon the existing medical care infrastructure.1,2,3

This infrastructure, which remained largely intact after theearthquake, allowed surgical teams to respond immediately, whileoperating rooms in Port-au-Prince were incapacitated. As ofJanuary 25, a total of 220 patients who had been injured inthe earthquake had checked into the Cange hospital. The hospitalcontinues to receive additional patients each day despite itsremote location. The local chapel and school have been convertedinto inpatient wards, but the hospital still bulges with patientssleeping in walkways, in hallways, and on patios. Additionalsurgical staff members were rapidly mobilized. We arrived onJanuary 16 as part of a team that included three surgeons (oneorthopedic and two plastic) to support the two general surgeons(one Haitian and one American) and local staff who were on siteat the time of the quake.

It took us several days to realize that what works for traumain the United States also works in Haiti. A system of triage,rounding, protocols, and sign-out gradually emerged from thechaos. Most of the patients who managed to get to Cange neededacute surgical care for crush injuries, fractured limbs, compartmentsyndromes, and massive wounds. In three operating rooms, visitingU.S. surgeons worked closely with Haitian colleagues and performed122 operations in the first 9 days, including amputations, fasciotomies,external fixation of fractures, wound closures and débridements,and exploratory laparotomies. Additional stations for lacerationrepair, wound care, and casting under ketamine sedation wereset up in the chapel.

But surgical teams are only the first phase of lifesaving interventions.We began to treat some patients for deep venous thrombosis inthe days after their surgery, and some patients died of whatseemed likely to be pulmonary emboli, prompting us to initiateheparin prophylaxis using standard protocols.4 Later in theweek, patients began having renal failure from rhabdomyolysis,so we opened dialysis centers. By the end of the week, the teamhad developed a rhythm.

Over the past 25 years, PIH and ZL have developed a system of“accompaniment” and currently employ more than 2000 accompagnateurs,or community health workers, hired because of their understandingof local people and communities. Accompagnateurs are trainedto administer medications, monitor patients for complicationsor adverse reactions to medications, answer questions aboutmedical conditions, and help patients seek medical care.5 Theseworkers will need to be trained in diagnosing and monitoringcomplications of surgery and in administering basic wound care,and PIH and ZL will have to make a long-term commitment to “accompanying”patients who received injuries necessitating surgery. Patientswho have undergone amputations must be taught to care for themselvesindependently so that, with support, they can remain activemembers of their community.

There will be no quick fix for the enormous number of injuriesinflicted by this disaster. Months and probably years of ongoingsurgical care will be necessary to prevent death and minimizedisability. For the first few weeks, health care providers willhave to focus on acute care — amputations, débridements,and fracture reductions. Wound care and wound closure will follow.The fitting of prostheses and rehabilitation will go on foryears to come. Meanwhile, though the earthquake has dramaticallychanged the landscape in Haiti, day-to-day surgical needs thatare unrelated to the earthquake will continue to require attention.In addition to the trauma cases in Cange, routine cases continueto be slipped into the surgical schedule — lymph-nodebiopsies for Hodgkin’s disease, incarcerated hernias, tumorexcisions.

If there is a silver lining in this event, it is that surgicalcare in Haiti will never be the same. Hundreds of nurses, surgeons,and anesthesiologists have been introduced to a country in need.Although medical care providers may have blazed the trails ofglobal health, surgeons are following. Haiti will not be forgotten.

Financial and other disclosures provided by the authors areavailable with the full text of this article at NEJM.org.

Source Information

From Partners in Health (S.R.S, H.O.B.T., M.L.S) and Harvard Medical School (T.P., M.L.S.) — both in Boston; and the Division of Plastic Surgery, Warren Alpert Medical School of Brown University (S.R.S, H.O.B.T.), and the Department of Plastic Surgery, Rhode Island Hospital and Hasbro Children’s Hospital (S.R.S., H.O.B.T.) — both in Providence, RI.

This article (10.1056/NEJMp1000976) was published on February 3, 2010, at NEJM.org


Stephen R. Sullivan, M.D., M.P.H., Helena O.B. Taylor, M.D., Ph.D., Thierry Pauyo, B.A., and Michael L. Steer, M.D.

 


References

 

  1. Farmer PE, Kim JY. Surgery and global health: a view from beyond the OR. World J Surg 2008;32:533-536. [CrossRef][Web of Science][Medline]
  2. Ivers LC, Garfein ES, Augustin J, et al. Increasing access to surgical services for the poor in rural Haiti: surgery as a public good for public health. World J Surg 2008;32:537-542. [CrossRef][Web of Science][Medline]
  3. Children’s Hospital Boston. Addressing the global burden of surgical diseases. December 2009. (Accessed February 2, 2010, at https://childrenshospitalblog.org/addressing-the-global-burden-of-surgical-diseases/.)
  4. Geerts WH, Bergqvist D, Pineo GF, et al. Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th edition). Chest 2008;133:Suppl:381S-453S. [Free Full Text]
  5. Mukherjee JS, Ivers L, Leandre F, Farmer P, Behforouz H. Antiretroviral therapy in resource-poor settings: decreasing barriers to access and promoting adherence. J Acquir Immune Defic Syndr 2006;43:Suppl 1:S123-S126. [CrossRef][Web of Science][Medline]

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