Limb Salvage In Haiti: Reflections From A Recent Mission Trip
Diabetes is the most common cause of non-traumatic amputation in the United States, according to the Centers for Disease Control and Prevention (CDC).1 Worldwide, the limb salvage picture is even more dire with one diabetes-related primary lower extremity amputation every 30 seconds, adding up to more than 2,500 limbs lost per day.2-4 Given that a projected 550 million people worldwide will have diabetes by 2030, limb salvage is taking on increasing importance, particularly in underserved populations.
Recently, we had the opportunity to function as a FootAid medical response team in support of an ongoing mission to provide limb-saving surgery for the underserved patient population in Port-au-Prince, Haiti. Beyond patient care, it is the mission of FootAid to educate local care providers around the world in a holistic approach to lower extremity care to provide sustainable solutions to improve foot and ankle health.
Nearly 50 health centers in Haiti were destroyed during a 7.0 magnitude earthquake that occurred in January 2010. Historically, these centers functioned as part of Haiti’s main teaching hospital and the country’s Ministry of Health. In the aftermath of the earthquake, United Nations sent aid and established a base in Port-au-Prince. Since that time, various non-governmental organizations (NGOs) have utilized this base as a headquarters of sorts from which to base their volunteer efforts. This work continues today.
According to recent statistics published by the World Bank, 59 percent of Haitians live on less than $2 a day.5 Indeed, 24.7 percent of the Haitian population live in what is categorized as “extreme poverty,” living on less than $1.25 a day. Access to health care is extremely limited and many of the people living and working in Port-au-Prince suffer from a variety of lower extremity ailments and disease processes, many of which have led to the development of chronic lower extremity wounds. According to the United States Agency for International Development, as of March 2017, about 40 percent of Haitians lacked access to essential health services.6 Seven and a half years after the earthquake, Haiti is still recovering. Diabetes is rampant but limited access to appropriate medical care creates a spiral of morbidity that commonly ends in loss of limb and ultimately loss of life.
As members of the FootAid medical response team, working in conjunction with elements of Project Medishare, a NGO that has been working to provide the Haitian people with medical volunteers since the catastrophic earthquake in 2010, volunteer clinicians and medical students work in conjunction with local surgeons and physicians in a variety of treatment environments including local hospitals, wound centers, and other health centers throughout Port-au-Prince. Through this grassroots approach, these collaborations are able to provide life-changing medical and surgical care to this grossly underserved patient population.
Recognizing And Adapting To The Surgical Challenges
On our first day in Port-au-Prince, we had the opportunity to treat patients in a clinic run by Fondation Haïtienne de Diabète et de Maladies Cardio-Vasculaires (FHADIMAC), a nonprofit organization that, through the efforts of volunteer Haitian and foreign doctors, works to provide improved access and care to patients living with diabetes and hypertension. The FHADIMAC clinic is divided into two main sections, one that is set up to provide diabetic foot care and screenings, and the other to treat more severe wounds and infections. The diabetic clinic has a very familiar feel. It runs smoothly and efficiently, and did not seem to be that different from a clinic in the United States.
However, the infectious disease and wound care facility at FHADIMAC was quite different. A shipping container was modified to provide a reasonably clean and well-lit space. Supplies were scarce. Essentially, the supplies consisted of just gauze, betadine, hydrogen peroxide and topical antibiotic and antifungal ointments. While this facility primarily focused as a diabetes-centric clinic, many of the patients who presented in the infection clinic had wounds as a consequence of other pathology, including HIV, Madura foot and sickle cell anemia among others. Several of the patients we saw in that clinic needed more aggressive interventions that could not happen in that space and we booked these patients for surgery to follow later in the week.
We spent our other days in Haiti at Hopital Bernard Mevs, a hospital in Port-au-Prince that is supported by Project Medishare. Adler Francius, MD, a general surgeon from Haiti specializing in wound care, maintains a vibrant wound clinic that is extremely busy. During the time at Hopital Bernard Mevs, Drs. Francius and the lead author performed many surgical procedures at the bedside, including extensive wound debridement, amputations, incision and drainage for limb-threatening infection, and correction of congenital forefoot deformities. All of these surgeries occurred with local anesthesia, often with the patient watching. None of the patients complained and only a few made facial expressions that indicated they were pain. The resilience of these patients was both surprising and impressive.
Performing surgery in the clinic was frustrating at times. Instruments and supplies were limited. Improvisation became a necessity as we progressed though these varied cases. The language barrier was also challenging. The two official languages in Haiti are French and Creole. Essentially, none of the patients we treated spoke English and few of the support staff and nurses did either. Despite this, through trial, error and essentially an ongoing game of charades, members of the medical response team were able to communicate with the patients and staff.
On the final day in Haiti, patients who we had seen earlier in the week and scheduled for surgery went to another local hospital, Hopital St. Louis, for surgery. These were cases that we could not handle safely in a clinic space with local anesthesia. The placement of the cases at Hopital St. Louis instead of Hopital Bernard Mevs was due to the difficulty in obtaining OR time in the extremely busy operating theater at Hopital Bernard Mevs.
Working in the ORs at Hopital St. Louis further highlighted the stark contrasts in the practice of surgery in Haiti in comparison to the U.S. and only reinforced the reality of the limited access to surgical supplies and equipment. While we dispose of much of the supplies following every surgical case in the U.S., surgeons reuse some supplies on subsequent patients in Haiti. Additionally, we found out there was no power equipment in this hospital. Accordingly, the senior author had to perform a transmetatarsal amputation with a 15 blade and a Gigli saw.
Other surgeries included the removal of a large plantar melanoma, several metatarsal head resections designed to surgically offload plantar forefoot ulcers and wound resections with transposition flaps.
In Conclusion
Our time in Haiti was quite an experience and we were all thankful for the opportunity to be a part of FootAid’s mission in Port-au-Prince. As an organization, FootAid continues to establish connections with healthcare providers around the world to elevate the level of foot and ankle care in underserved populations. Further upcoming medical response team missions that we are planning include Amman, Jordan and Mongolia.
The senior author intends to return to Haiti to follow up on the patients he treated during his first trip and continue to work with Dr. Francius and other Haitian healthcare providers in order to develop a sustainable diabetic limb preservation program in Port-au-Prince.
Ms. Golding is a second-year student at the Temple University School of Podiatric Medicine and serves as a Student Ambassador for FootAid.
Ms. Barbe is a second-year student at the Temple University School of Podiatric Medicine and serves as a Student Ambassador for FootAid.
Dr. Fitzgerald is an Associate Professor of Surgery at the University of South Carolina. He is board-certified in both reconstructive rearfoot and ankle surgery, and foot surgery by the American Board of Foot and Ankle Surgery.
References
- Centers for Disease Control and Prevention. Diabetes data and statistics. Available at https://www.cdc.gov/diabetes/data/index.html . Published July 17, 2017.
- Armstrong DG, Wrobel J, Robbins JM. Guest Editorial: are diabetes-related wounds and amputations worse than cancer? Int Wound J. 2007; 4(4):286-7.
- Bharara M, Mills JL, Suresh K, Rilo HL, Armstrong DG. Diabetes and landmine-related amputations: a call to arms to save limbs. Int Wound J. 2009; 6(1):2-3.
- Fortington LV, Geerzten JHB, van Netten JJ, Postema K, Rommers GM, Dijkstra PU. Short and long term mortality rates after a lower limb amputation. Eur Soc Vasc Surg. 2013; 46(1):124–130.
- The World Bank in Haiti. Available at https://www.worldbank.org/en/country/haiti/overview . Published April 11, 2017.
- USAid. Haiti. Available at https://www.usaid.govhttps://s3.amazonaws.com/HMP/hmp_ln/imported/documents/1862/FINAL_Health_March_2017.pdf.
Editor’s note: For more information regarding FootAid, its mission in Haiti and other missions around the world, please visit www.footaid.org.
