Volunteer support and equipment are still needed

A year and a half after a catastrophic earthquake devastated Haiti, the tiny island nation is still struggling to rebuild. The 7.0-magnitude quake reduced the capital city of Port au Prince to rubble, knocked out all essential services, and killed more than 300,000 Haitians. Many survivors sustained serious orthopaedic injuries including crush injuries, compartment syndromes, and open fractures.

Immediately following the disaster, the AAOS took steps to provide support for both immediate and long-term relief efforts in Haiti. The Academy’s international department served as a clearinghouse, assisting members with volunteer applications and providing information.

In the days and weeks that followed, hundreds of AAOS members made arrangements to volunteer. Those with previous connections to the island rapidly deployed. Once they arrived in Haiti, the sheer devastation, coupled with an already fragile medical infrastructure, presented significant challenges, which were met with ingenuity, skill, and humanity. What these early responders managed to accomplish—treating seriously injured patients in makeshift facilities with limited equipment—was nothing short of miraculous.

An ongoing struggle
Fast forward 18 months and the situation in Haiti remains nearly as dire as it was in January 2010. A cholera epidemic has claimed thousands of additional lives. Reconstruction and rebuilding efforts have been slow, and although orthopaedic equipment and supplies eventually made their way in to the country, the need for long-term medical support and training is evident.

“Haiti has only a handful of trained orthopaedic surgeons, and many of the medical institutions that existed before the earthquake have yet to be rebuilt,” said Lynne Dowling, director of the AAOS international department.

“We need help,” added Terry J. Dietrich, MD, who, along with his wife, has been in Haiti since November 2010.

Dr. Dietrich came to Haiti to relieve his friend Scott Nelson, MD, who had been working nearly continuously for three months in Port au Prince. Realizing the need for a long-term commitment, Dr. Dietrich resigned his full-time position at home to volunteer at HÔpital Adventiste d’Haiti (HAH) for one year.

“Our work here has been nonstop,” he said. “I originally envisioned full-time help from my colleagues in the states, with teams arriving every week or two. The initial response was great, but now that enthusiasm has moderated and I am alone.”

Since the quake, the hospital has become a magnet for thousands of Haitians who in the past did not have access to good orthopaedic treatment. Dr. Dietrich only gets help from a single orthopaedist one week per month. “At times we have as many as 20 patients hospitalized with wound vacs or diabetic infections as well as recent trauma transfers. If I had enough anesthesia and orthopaedic help, I could schedule 10 or more cases every day,” he said.

In addition to limited staffing, HAH is forced to make do with outdated radiology equipment, no blood bank, lab facilities that are severely lacking, and small operating rooms with poor lighting and environmental control. Despite the inadequacies, the hospital performs a large number of procedures and the infection rate for elective procedures is very low.

“We do a large number of arthroscopies. I recently performed the country’s first two anterior cruciate ligament reconstructions and I hope to start a total joint replacement program,” said Dr. Dietrich. “We also do many SIGN nails, hip prostheses, clubfoot corrections, genu valgum and varum corrections, sequestrectomies, spine stabilizations, pelvic osteotomies, joint contracture releases, and joint fusions.”

In addition to orthopaedic surgeon volunteers, orthopaedic physician assistants, residents, anesthesia providers, orthopaedic technicians, and operating room and post-anesthesia care unit nurses are also needed, according to Dr. Dietrich.

“The work here is unbelievably rewarding. We have the unprecedented opportunity to establish an orthopaedic center that can provide high-quality care to the indigent people of Haiti. Although they are dirt poor, these people are very real and very family-oriented—they have lives,” he said. “I am sure that dozens, if not hundreds, of compassionate AAOS members would be willing to participate in a project as worthwhile as this.”

Training is key to rebuilding
“The crisis of a year and a half ago in Haiti has matured,” said George S.M. Dyer, MD, orthopaedic advisor for Partners in Health (PIH), which received a $12,500 grant from the AAOS last year.

Haitians are now experiencing chronic problems associated with orthopaedic injuries that went untreated, as well as complications such as infections, malunions, and nonunions. A steady influx of new injuries unrelated to the quake continues to tax the country’s orthopaedic infrastructure. PIH volunteers are currently working in small groups with Haitian healthcare providers to address these challenges.

“Our philosophy has always been to help Haiti’s doctors and nurses—to work with them, not to replace them,” said Dr. Dyer.

PIH is also focused on restoring high-level orthopaedic training in Haiti. The headquarters for Haiti’s national orthopaedic training program, HÔpital de l’Université d’Etat d’Haiti (HUEH) in Port au Prince, however, was badly damaged and is struggling to recover. Thanks to an agreement brokered by PIH, HUEH orthopaedic residents will do rotations at l’HÔptial St. Nicolas in St. Marc, which was spared significant damage during the earthquake and where teams of PIH volunteers have been working for the last several months.

“Two residents at a time, a second-year resident and a final-year resident, will rotate at St. Nicolas,” said Dr. Dyer. “The 150-bed hospital has two fully functioning operating rooms and, thanks to a team from Sutter Health in California, it now has a C-arm imaging system and full-size sterilizer.”

PIH has also arranged for visiting teams to come to the St. Marc facility every 6 weeks to assist the local staff in teaching an organized curriculum to residents.

Building ongoing relationships
Located 70 miles from Port au Prince, the city of Milot, Haiti, also sustained minimal damage from the earthquake. Milot’s HÔpital Sacre Coeur, with its two operating rooms and own water and power supply, was fully functional after the disaster and treated many of the most severely injured victims from surrounding areas.

For more than 10 years, John Lovejoy Jr., MD, has been making regular medical missions to Sacre Coeur through the CRUDEM Foundation. Four days after the earthquake, Dr. Lovejoy and a team of two orthopaedic surgeons, two nurses, and one physician’s assistant were on the ground in Haiti and treating patients. The medical team performed more than 180 surgeries in one week. “Sixty percent of our surgeries were amputations. We constructed a prosthetic lab to make artificial limbs for the amputees. Despite their enormous tragedy, we sensed the enduring spirit of the Haitian people and their determination to survive,” he said.

That determination and his personal enthusiasm help drive Dr. Lovejoy’s long-term efforts in Haiti. Visiting specialty teams travel to Sacre Coeur throughout the year. “The most exciting thing for me was working with my son, a third-generation orthopaedist. At present, we have four orthopaedic teams that bring residents, anesthesiologists, operating room nurses, physical therapists, support staff, and more,” he said. “The goal is to give the Haitian healthcare community the tools, supplies, and training necessary to provide good medical care to their fellow countrymen.”

The AAOS commitment
The AAOS is committed to helping Haiti rebuild and strengthen its orthopaedic infrastructure by connecting AAOS members with nongovernmental organizations assisting in Haiti.

Maureen Leahy is assistant managing editor of AAOS Now. She can be reached at leahy@aaos.org

AAOS-OTA update
Haiti Relief and Disaster Preparedness Project Team
Shortly after the earthquake in Haiti, the AAOS Board of Directors formed a project team composed of representatives from the AAOS and the Orthopaedic Trauma Association (OTA). Co-chaired by Christopher T. Born, MD, and David Teuscher, MD, the AAOS-OTA Haiti Relief and Disaster Preparedness Project Team was charged with assisting the revitalization of orthopaedic education in Haiti and developing a formal disaster preparedness plan that will serve as a blueprint for future orthopaedic disasters. AAOS Now spoke with Dr. Born about the status of the Project Team’s initiatives.

AAOS Now: With regard to Haiti relief, what has been accomplished so far?
Dr. Born: The AAOS has donated a total of $50,000 to four nongovernmental organizations (Partners in Health, SIGN, Handicap International, and the International Medical Corps) to be used specifically for relief work in Haiti. In addition, the Academy has contributed a vast electronic library of orthopaedic information and educational tools to Société Haitienne de Traumatologie et d’Orthopedie (SHOT).

OTA President Andrew N. Pollak, MD, who works closely with the Project Team, has been working with Catholic Relief Services and the National Institutes of Health on a 2-year trauma training program to teach Haitian physicians how to manage basic orthopaedic trauma and musculoskeletal injuries. The first group of trainees will be in place within the next 6 months. In January 2011, we turned the Haiti Relief component of the plan over to the AAOS International Committee.

AAOS Now: What is the status of the disaster preparedness plan?

Dr. Born: Our work on the formal disaster preparedness plan is focused on educating, credentialing, and certifying orthopaedic surgeons for volunteering in austere environments during a disaster. The Society of Military Orthopaedic Surgeons (SOMOS) is helping by modifying its Extremity War Injuries Course for civilian orthopaedic surgeons. The course, which includes both didactic and cadaver learning components, will have five or six OTA surgeons as faculty. The course will be rolled out at the 2011 SOMOS Annual Meeting in December in San Diego, and, hopefully be repeated at the 2012 AAOS Annual Meeting in San Francisco.

We are also developing a centralized database of credentialed volunteer responders. We are working with the surgeons general of the Army, Navy, and Air Force to develop closer working arrangements with the military and to precertify orthopaedic trauma surgeons who can provide surge coverage in the event of a national or international disaster.

Before this can happen, however, legislative, licensing portability, and liability barriers must be addressed. Who is responsible for the care of medical responders if something happens to them? We are working on identifying key people at the Department of Health and Human Services or the Department of Defense who can help with this. An obvious solution would be to make volunteer responders temporary government employees who would then be covered under a federal umbrella.

AAOS Now: What is your timeline for having these things in place?

Dr. Born: Our recommendations will be presented to the AAOS Board of Directors at their June meeting. Making recommendations is one thing, but making them happen is quite another. It gets into politics—it’s my belief that we’ll need to get federal legislation through Congress to change some the current laws and the states will also get involved. I think it will probably be 2013 before we have everything in place.

The AAOS and OTA have been working hand in hand and have really opened the doors to making this happen. Once completed, the orthopaedic surgery response program may also serve as a model for other specialty societies. We are very forward thinking on this—we’re ahead of the curve in terms of what we are doing compared to other societies. The fundamental components have been identified and the members of the Project Team have worked very hard to keep this moving forward.