A Surgical Remedy, By Dr. Greg Elder

July 29, 2010

This article is part of the Spring 2010 issue of the MSF Alert newsletter.

In the days following the earthquake in Haiti, I was asked in a CNN interview about the rescue of an 11-year-old girl who was partially trapped under a building. It was a compelling story: an innocent victim crying in pain, newly-arrived search-and-rescue teams racing against the clock in an apocalyptic cityscape, and an ethical dilemma over whether to risk the girl’s life by performing a crude amputation or attempting a slow rescue. It was an awkward question for a doctor to face on national television. I wondered if I was being asked to comment on the scene or to give a professional opinion on what should be done.

Later in the day, I was dealing with the events ongoing at MSF’s centers in Port-au-Prince. Our hospitals had been damaged and staff members were missing. Our traumatized teams were struggling with the overwhelming numbers of patients flooding into the facilities they’d established where our trauma center once stood. Our emergency response team was plotting out our phased response strategy and calling high-level contacts in regional governments to request facilitation of our efforts. My mind drifted back to the little girl and I wondered if anything I’d said might have been construed as professional advice to amputate her leg and to move to the next case.

Doctors are trained to make these decisions and to live with their consequences. As a doctor working for a humanitarian organization, I am buffered from the personal impact of such choices. At headquarters level, patients can become abstract categories: victims, displaced, refugees, and so on. MSF conducts more than 8 million consultations a year in nearly 70 countries. That’s 8 million individual conversations between a health worker and a patient. They could happen under a tent in a mobile clinic in Darfur, at an HIV center in Malawi, or in a trauma hospital in Port-au-Prince. This is the measure of MSF’s human reach. This is the “human” in humanitarian. And, from time to time, even for those of us at headquarters, one patient can alter that abstract relationship and make the decisions very real.

What could be the future of this little girl? What are the implications of my advice? Her leg was probably crushed. Pulling her out with her leg intact was unlikely. Reperfusion of her damaged limb could provoke crush syndrome and put her in mortal danger. Sepsis, gangrene, and tetanus are also risks. But amputating her leg would be only the first chapter. She would subsequently need intensive medical management —surgical debridement of her wound, fashioning of the stump, physiotherapy and planning for an artificial limb–that would require specialists and long-term follow-up care. She would need several new prostheses as she grows, and she will also almost certainly need psychological support to cope with the loss of her limb, the trauma and post-trauma of her experience, and the grief associated with losing friends and family.

Services such as these were extremely limited in Haiti even before the earthquake (and almost wholly inaccessible if one didn’t have money). MSF set up Trinité hospital in 2005, when urban warfare was raging in Port-au-Prince. For the last two years, it’s been the capital’s sole trauma center, treating fewer war-wounded and rape victims but increasing numbers of people for motor vehicle, domestic, and workplace accidents. MSF also ran the city’s primary obstetric unit—providing obstetric care to some 25,000 pregnant women since 2006, almost 60 percent of whom were facing potentially life-threatening complications—while also providing primary and basic secondary health services in several city slums.

On top of this girl’s short-term and long-term medical needs, one wonders how a young woman—possibly on her own, with a significant physical disability—will negotiate a crowded marketplace in a poor country that still lacks meaningful social safety nets despite the billions that have been invested in development aid and a UN peacekeeping operation.

The proposed amputation to save this girl’s life is a calculated surgical act, at once aggressive and compassionate. A similarly aggressive and targeted approach is needed for the long-overdue reconstruction of Haiti’s health system. If it can be done, this young woman might not have to bear the burden of her collapsed house for the rest of her life.

Dr. Greg Elder is MSF-USA’s Deputy Operations Manager

 

Tags: Surgeon, Surgery, Physician, Haiti, Haiti Earthquake 2010