Surgeon seeks to prevent 'unnecessary amputations' in Haiti's earthquake zone

This gallery collects all of our photos of the crisis in Haiti, starting with the most recent images and going back to the first photos that emerged after an earthquake hit the impoverished nation Jan. 12.
By David Brown
Thursday, January 21, 2010

PORT-AU-PRINCE, HAITI -- Much has been made of how natural disasters like Haiti's earthquake temporarily plunge medicine back into the era of the Civil War. Waseem Saeed is determined that doesn't happen on his watch.

The 46-year-old plastic surgeon from northern England is here in the Haitian capital to salvage limbs. He wants to avoid the quick but life-altering amputations that were the standard -- although not universal -- treatment for severe limb wounds 150 years ago.

His mission is difficult, he acknowledges. He and other surgeons only now arriving in this devastated city face the certainty that most crushed and broken limbs are starting to get infected. If the limbs aren't treated soon, the surgeons will be resigned to two courses of action -- amputation or a long series of operations that will be difficult to perform under the prevailing circumstances.

Saeed spent Wednesday morning inspecting cuts and changing dressings. By noon he had three patients, all younger than 5, booked for surgery as soon as equipment sent by the British medical charity Merlin -- and weighing about 11,000 pounds -- was set up. Meanwhile, Merlin's 40 local employees were erecting surgical tents on five largely intact tennis courts near the city center.

"You shouldn't amputate every complex injury you see in an earthquake zone," said Saeed, who has done surgical relief work at the sites of four earthquakes in recent years. "In Pakistan [in 2005], patient after patient was lined up for an amputation. We saved their limbs."

His opinion, somewhat at odds with conventional wisdom, is that disaster-zone surgery has too closely followed the experience of battle-zone surgery. He said wounds requiring amputation in the latter scenario may not need such surgery in the former one -- even if they look pretty much the same to the naked eye.

The key difference, he said, is that high-energy gunshot wounds cause wide but not always visible injury that make salvage much more difficult. Bullets and shrapnel drive clothing, skin and dirt deep into tissue, increasing the risk of delayed infection.

Earthquake injuries have their own problems, including the dreaded "crush syndrome," which can kill pinned victims within minutes of rescue. But in Saeed's experience, such wounds are often less hopeless than many surgeons assume.

"The tissue outside the injury may be healthy, especially in children," he said. Then, after a pause, he added: "The reason I'm here is to prevent unnecessary amputations. To do that, you need plastic surgeons to come out with orthopedic surgeons."

Merlin, which specializes in emergency response as well as long-term efforts to improve the health-care systems of countries in dire need, has both types of surgeons in Haiti. An orthopedist and physician epidemiologist arrived last weekend. Saeed, three emergency physicians, three nurses, an anesthesiologist and their attendant logisticians and managers arrived Tuesday night.

How much is possible eight, nine or 10 days after injury was a matter of debate Wednesday morning as the Merlin medical team gathered on the terrazzo pool deck at a hotel near the city's airport where its members had spent the night in tents.

Richard Villar, a tall and seemingly unflappable orthopedist from London who served for many years in the British army's special forces, had spent the previous day assessing injured Haitians at an open-air clinic. He said he wanted Saeed to see several of them.

"I suspect you'll say there is infection there and you can't do much," Villar said.

The slight and quiet Saeed said it might still be possible to clean an open leg fracture wound in one operation and then close it with a skin flap in another. If the surgeons don't get started soon, though, such salvage would require three or four preparatory operations and, at some point, would become impracticable.

As for the Civil War, records from the Union army showed that 71 percent of all immediately nonfatal wounds were in the arms or legs, according to the 1996 book "Orthopaedic Injuries of the Civil War." The mortality rate from wounds alone -- not counting various communicable diseases that plagued both armies -- was 14 percent. For complex or infected extremity wounds, especially involving broken bones, amputation was the only choice. Nearly half a million men came out of the war permanently disabled.

Saeed said limb salvage is especially important in developing countries, where disability often spells ostracism and lifelong penury. Research has shown that a poorly functioning arm is better than no arm -- just about everywhere.

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