Globe Staff / January 21, 2010
PORT-AU-PRINCE, Haiti – One finger was already gone, stolen by the brutality of last week’s earthquake. Two other fingers on the teenager’s right hand hung mangled and swollen by infection.
The decision was clear, especially here, in a field hospital with limited resources, in a city where the medical network has collapsed: The fingers would have to be amputated.
“These two fingers, they’re dead,’’ said Dr. David Mooney, chief of trauma services at Children’s Hospital Boston, who came here last week as part of a government medical response team. He locked eyes with the boy and his father in a tent clinic, his voice compassionate. “These are no good. I’m very sorry.’’
The father lifted his hands skyward.
This is catastrophe medicine, where resources are scarce, time short, options few. It is a world apart from the exacting standards of the high temples of modern medicine in Boston and other US cities where members of two disaster teams now working in a Port-au-Prince school yard usually ply their trade.
Here, they conduct surgery inside a sweltering tent without high-beam surgical lights or stools for the surgeons. Supplies dangle from the walls, and what passes for an operating table doesn’t move up and down.
“You’ve got to do stuff you just wouldn’t do in the States,’’ Mooney said. “You’ve just got to go back to 1930s surgery. . . . Even if it means losing another finger – that’s what you’ve got to do.’’
Anesthesia equipment turns temperamental in the heat. Some supplies are so scarce they are reused. There are no fancy MRIs.
On Tuesday, when the International Medical Surgical Response Team began performing operations, Dr. Christopher Born stood under a portico, peering at an X-ray that a patient had brought from another medical facility. The sky was his light table.
The earthquake shattered her hip and thigh bone. In the United States, surgeons repairing such injuries usually work from roadmaps generated by operating room X-ray machines.
With no such equipment here, the woman was urged to seek care at one of the full-service hospitals that survived the quake.
“At this facility, given our capabilities for something like this, we could try to do something, but we might do more harm than good,’’ said Born, chief of orthopedic trauma at Rhode Island Hospital.
“One of the mantras for disaster medicine,’’ he said, “is the greatest good for the greatest number of people.’’
For medical specialists from the United States, that sentiment turns the practice of medicine on its head. That’s particularly the case for physicians from elite teaching hospitals, where bounteous medical resources are expended on saving the sickest patients.
Not long after Dr. Annekathryn Goodman of Massachusetts General Hospital landed at the field hospital this week, she encountered a 57-year-old man whose spinal cord was broken in the earthquake. His kidneys were failing. His heart, too.
In Boston, Goodman said, the man would undergo a battery of evaluations. He would have the option of aggressive interventions such as kidney dialysis. Here, choices are scant.
“There’s no dialysis here. There’s no real intensive care unit, and there’s no Spaulding Rehab [Hospital]to send him to for intensive rehab therapy for six months or a year,’’ said Goodman, a gynecologic oncologist.
The man died at the field hospital.
Doctors toiling in disaster zones also must be realistic about the circumstances into which patients are discharged. A life spent in squalor and privation is incompatible with an extended, difficult recovery from surgery.
And, yet, in the past two days, lives have been saved in the cramped operatingroom, broken bones fixed – in no small part because of the ingenuity and experience of the medical workers.
A 40-year-old woman entered the OR with two broken thigh bones. To stabilize the bones, surgeons screwed onto each leg something called an external fixation device, which, to the untrained eye, resembles a medieval torture apparatus. Consisting of carbon fiber rods, stainless steel pins, and clamps, it was the standard of care in America 25 years ago. Today, surgeons in an American OR are more likely to use titanium nails, which are not available at the field hospital.
As surgeons began the operation on Tuesday evening, even the little things spoke to the differences in practicing medicine amid a disaster. To conserve the sheets used to cover patients, for example, the woman had just a single drape placed over her. And sensors placed on her chest to monitor her heart had been recycled from previous patients.
“We’re essentially driving by the seat of our pants,’’ said Dr. Judy O’Young, an anesthesiologist with Kaiser Permanente in California. “Somebody fresh out of training would freak out.’’
O’Young was in charge of anesthesia for Marons Simon, the 14-year-old with the mangled fingers. His was the first surgical case in the field hospital on Tuesday. Born washed up in an outdoor sink, using bottled water because the tap was dry.
Wearing a blue gown, yellow gloves, and Philadelphia Eagles bandana, he used a surgical saw to amputate the fingers. He perched on two black plastic crates. About 10 minutes into the procedure, the anesthesia machine suddenly went silent.
“I was afraid of that,’’ O’Young said. “We’ll be fine for 5 or 10 minutes. Work fast, guys.’’
The machine was humming again in less than 10 minutes, but would shut down once more 20 minutes later, as the surgery was wrapping up. Heat was the likely culprit.
The teenager, stoic when he was diagnosed, stoic as the surgery began, awoke with a start. His hand was bandaged, the two fingers gone.
His father, Brinele Simon, said through a translator in the recovery room that he “thanks the Americans, very much.’’
Then father and son slowly walked through the school’s gate, the father grasping his son’s intact left hand.
Stephen Smith can be reached at stsmith@globe.com.
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