Amputation in emergency situations: indications, techniques and Médecins Sans Frontières France's experience in Haiti

The role of Mangled Extremity Severity Score in amputation triage in a transport health facility with catastrophic earthquake admissions

BACKGROUND

The purpose of this study is to assess the diagnostic utility of the Mangled Extremity Severity Score (MESS) in the prediction of amputation after a major earthquake, and its utility in disaster triage.

METHODS

Study results were presented from a tertiary hospital in Diyarbakır, which was affected by the earthquake but served as a transport hub for other cities in the region affected by the earthquake. MESS was calculated and its diagnostic value is analyzed in predicting amputations. MESS scores were divided into low risk, intermediate risk, and high risk groups by the researchers based on their diagnostic value analysis.

RESULTS

79 patients were included in the study. Based on the outcome of amputation or salvage, patients were divided into two groups. 24.1% (n = 19) of the patients had amputations. Both gender and mean age did not differ statistically significantly between the groups (p > 0.05). Compared with the salvage group, the amputation group had a significantly longer prehospital stay and higher rate of vascular injury and higher median MESS (p = 0.007, p < 0.001, p < 0.001; respectively). Based on MESS scores, amputation outcomes were predicted with an accuracy of 0.889 (95% CI 0.798-0.949). Those with a MESS score below 9 were considered low risk (sensitivity = 100%) whereas those with a MESS score above 12 were considered high risk (specificity = 98.33%).

CONCLUSION

In transport centers, MESS may be useful for surgical triage of earthquake-induced limb crush injuries.

Traumatic Injuries are the Main Indication for Limb Amputations During and After Humanitarian Crises

BACKGROUND

Populations at risk during humanitarian crises can suffer traumatic injuries or have medical conditions that result in the need for limb amputation (LA). The objectives of this study were to describe the indications for and associations with LA during and after humanitarian crises in surgical projects supported by Médecins Sans Frontières (MSF).

METHODS

MSF-Operational Center Brussels data from January 1, 2008, to December 31, 2017, were analyzed. Surgical projects were classified into (annual) periods of crises and post-crises. Indications were classified into trauma (intentional and unintentional) and non-trauma (medical). Associations with LA were also reported.

RESULTS

MSF-OCB performed 936 amputations in 17 countries over the 10-year study period. 706 (75%) patients were male and the median age was 27 years (interquartile range 17-41 years). Six hundred and twenty-one (66%) LA were performed during crisis periods, 501 (53%) during conflict and 119 (13%) post-natural disaster. There were 316 (34%) LA in post-crisis periods. Overall, trauma was the predominant indication (n = 756, 81%) and accounted for significantly more LA (n = 577, 94%) in crisis compared to post-crisis periods (n = 179, 57%) (p < 0.001).

DISCUSSION

Our study suggests that populations at risk for humanitarian crises are still vulnerable to traumatic LA. Appropriate operative and post-operative LA management in the humanitarian setting must be provided, including rehabilitation and options for prosthetic devices.

Trends in Demographics and Surgical Treatment of Weapon-Related Limb Injuries Over Two Decades in a Resource-Scarce Setting

BACKGROUND

In the past decades, surgical management of limb injuries in high-resource settings has improved. The possibility of limb salvage has increased. It is not known whether similar changes have transpired in resource-scarce conflict settings.

METHODS

Retrospective cohort study using routinely collected patient data from the International Committee of the Red Cross hospitals in Pakistan was conducted. Consecutive data from 2009 to 2012 (535 patients) and randomly selected data from 1992 to 1995 (463 patients) were used. Only patients with weapon-related limb injuries were included. Differences in surgical procedures were assessed with logistic regression to adjust for confounding factors.

RESULTS

Less injuries were related to mines in 2009-2012 than in 1992-1995 (3.7% vs. 20.3%, p < 0.0001), but injuries from bombs, shells and fragments were more frequent (38.5% vs. 19.4%, p  < 0.0001) as were injuries with only a small degree of tissue damage (42.0% vs. 31.1%, p  = 0.0004). In the logistic regression, the time period did not affect the risk of amputation, debridement, length of hospital stay or in-hospital mortality. The use of external fixation (OR 0.56, 95% CI 0.33-0.96, p  = 0.04), split skin grafts (OR 0.31, 95% CI 0.21-0.45, p  < 0.0001) and blood transfusion (OR 0.43, 95% CI 0.28-0.66, p  = 0.0001) was less frequent in 2009-2012.

CONCLUSION

In this resource-scarce conflict setting, the risk of amputation appears unchanged over time, while the use of external fixation and split skin grafts was less common in 2009-2012 than in 1992-1995. These results contrast with the improved limb salvage results seen in high-resource settings. It likely reflects the challenges of providing advanced limb-preserving techniques in a resource-scarce setting.

Honey-Based Salve and Burdock Leaf Dressings as an Alternative to Surgical Debridement of a Traumatic Wound Eschar

Objective: Nonviable necrotic eschar is an impedance to wound healing and can ultimately lead to failure of soft tissue coverage in traumatic or high-risk wounds. Topical therapeutic agents can provide a less invasive management alternative to surgical debridement of eschar.

Approach: The case of a 40-year-old male with a traumatic right lower extremity amputation complicated by surgical incision ischemic eschar formation is reported. Honey-based salve with burdock leaf dressings was used to noninvasively manage eschar extending over the incision site. Images were obtained for 5 months of follow-up.

Results: Five-month follow-up demonstrated complete resolution of eschar and re-epithelialization of skin in the affected region.

Innovation: Honey-based salve with burdock leaf dressings shows promise for enhancing healing outcomes in traumatic wounds that develop nonviable eschar.

Conclusion: Surgical debridement of an amputation stump with large ischemic eschar was avoided with the use of honey-based salve with burdock leaf dressings.

Quality orthopaedic care in sudden-onset disasters: suggestions from Médecins Sans Frontières-France

A huge change is needed in the conception and implementation of surgical care during sudden-onset disasters (SOD). The inadequate surgical response mounted by the majority of foreign medical teams (FMT) after Haiti's earthquake is a striking example of the need for a structured professional approach. Logistical capacity already exists to provide safe, timely, effective, efficient, equitable and ethical patient-centred care with minimum standards. However, knowledge, skills and training in the fields of general, orthopaedic and plastic surgery need further clarification. Surgical activity data and clinical examples from several Médecins Sans Frontières-France (MSF) projects are used here to describe the skill set and experience essential for surgeons working in SOD contexts.

[The nursing role in field amputation]

Field amputation is a surgical procedure which consists in removing one or several limbs of a victim to extricate them from rubble and evacuate them to a hospital. A last resort, it is a rarely-performed procedure, carried out primarily in disaster medicine. A team which worked in Haiti after the 2010 earthquake reports on one such clinical situation.

Saving life and limb: limb salvage using external fixation, a multi-centre review of orthopaedic surgical activities in Médecins Sans Frontières

Purpose

While the orthopaedic management of open fractures has been well-documented in developed settings, limited evidence exists on the surgical outcomes of open fractures in terms of limb salvage in low- and middle-income countries. We therefore reviewed the Médecins Sans Frontières-Operational Centre Brussels (MSF-OCB) orthopaedic surgical activities in the aftermath of the 2010 Haiti earthquake and in three non-emergency projects to assess the limb salvage rates in humanitarian contexts in relation to surgical staff skills.

Methods

This was a descriptive retrospective cohort study conducted in the MSF-OCB surgical programmes in the Democratic Republic of Congo (DRC), Afghanistan, and Haiti. Routine programme data on surgical procedures were aggregated and analysed through summary statistics.

Results

In the emergency post-earthquake response in Haiti, 81 % of open fracture cases were treated by amputation. In a non-emergency project in a conflict setting in DRC, relying on non-specialist surgeons receiving on-site supervision and training by experienced orthopaedic surgeons, amputation rates among open fractures decreased by 100 to 21 % over seven years of operations. In two trauma centres in Afghanistan (national surgical staff supported from the outset by expatriate orthopaedic surgeons) and Haiti (national musculoskeletal surgeons trained in external fixation), amputation rates among long bone open fracture cases were stable at 20 % and <10 %, respectively.

Conclusions

Introduction of and training on the proper use of external fixators reduced the amputation rate for open fractures and consequently increased the limb salvage rates in humanitarian contexts where surgical care was provided.

Trauma consults on humanitarian surgery trips: A perspective on the Haitian trauma system and the humanitarian’s role

Ubiquitous access to surgical care, especially trauma surgery, is recognized as an essential component of public health. We present two trauma cases—an upper arm machete laceration and a penetrating chest wound—that highlight barriers facing trauma patients in Haiti and describe how it relates to humanitarian surgery trips. An Emory University student–faculty collaborative, partnering with the non-profit Project Medishare (PM) for Haiti since 2008, provides elective and urgent surgical care to the underserved population of the Haitian Central Plateau. This partnership collaborates with a main referral center known for providing quality surgical care at little or no cost. Elective urological and general surgical cases comprise the bulk of the case load but urgent trauma services have been provided when required. Future trauma system initiatives must focus on increasing access to vehicles, telecommunications, and first responders. Our recommendations are reinforced by preliminary results from a trauma needs assessment performed in the Central Plateau and surrounding departments during July 2013. Humanitarian teams can contribute by preparing for emergencies prior to departure and sharing new procedural knowledge with local providers. Supplementing the ability to intercede in emergency surgical situations furthers the goal of short-term surgical trips to diminish indigenous patient morbidity and mortality. We advocate extensive preparation for such situations and increased bidirectional knowledge sharing with local staff.

Study of the severity of musculoskeletal injuries and triage during the 2005 Pakistan earthquake

PURPOSE

On 8 October 2005 a massive earthquake hit the northern mountainous areas of Pakistan and Kashmir causing 73,338 deaths and leaving over 125,000 severely injured. In a region which was less prepared for such an enormous disaster, mobilising rescue, relief and rehabilitation posed great challenges. The first author (SMA) established two level 1 orthopaedic trauma and rehabilitation units in each of two severely hit major cities through private philanthropy. According to the severity of injuries, the patients were triaged and treated. The aim of this study is to improve the future strategies in similar scenarios.

METHODS

This is a retrospective review of medical records of patients suffering from musculoskeletal injuries in the aftermath of the 2005 earthquake who were managed in these centres in the order of triage priority. The patients were received, categorised, worked up and provided definitive surgical procedures. All patients were provided assistance for the fitting of a prosthesis and rehabilitation.

RESULTS

Of 128,304 (total of injured patients), 19,700 were managed in two centres established by SMA during the first months after the earthquake. Of these, 112 patients underwent amputations of upper and lower limbs.

CONCLUSIONS

In a massive calamity over a wide geographical area away from big university hospitals, such as the 2005 Pakistan earthquake, the level 1 operating theatre facilities must be established within the area to meet the immediate needs of the patients nearest to their homes and families, and run forever so that patients can have excellent follow-up and can use the same facilities regularly. In the aftermath of this earthquake the need to practise triage in the first 72 hours was thoroughly realised and effectively practised in our centres.

Triage in surgery: from theory to practice, the Medecins Sans Frontières experience

Establishing triage is necessary in mass casualty events. If the concept of triage itself is easy, its application in the field encounters many difficulties at times unforseen. MSF offers a list of the main obstacles encountered when establishing an efficient triage system.

Review of Van earthquakes form an orthopaedic perspective: a multicentre retrospective study

PURPOSE

This is a descriptive analysis, of victims of Turkey's October 23, 2011 and November 21, 2011 Van earthquakes. The goal of this study is investigated the injury profile of the both earthquakes in relation to musculoskeletal trauma.

METHODS

We retrospectively reviewed medical records of 3,965 patients admitted to in seven hospitals. A large share of these injuries were soft tissue injuries, followed by fractures, crush injuries, crush syndromes, nerve injuries, vascular injuries, compartment syndrome and joint dislocations. A total of 73 crush injuries were diagnosed and 31 of them were developed compartment syndrome.

RESULTS

The patients with closed undisplaced fractures were treated with casting braces. For closed unstable fractures with good skin and soft-tissue conditions, open reduction and internal fixation was performed. All patients with open fracture had an external fixator applied after adequate debridement. Thirty one of 40 patients with compartment syndrome were treated by fasciotomy. For twelve of them, amputation was necessary. The most common procedure performed was debridement, followed by open reduction and internal fixation and closed reduction-casting, respectively.

CONCLUSIONS

The results of this study may provide the basis for future development of strategy to optimise attempts at rescue and plan treatment of survivors with musculoskeletal injuries after earthquakes.

An analysis of risk factors associated with traumatic extremity amputation stump wound infection in a Nigerian setting

PURPOSE

We aimed to determine the risk factors associated with traumatic extremity amputation stump wound infection in our environment.

METHOD

This was a retrospective analysis of databases that included the entire patient population with traumatic extremity amputation seen in Ebonyi State University Teaching Hospital and Federal Medical Centre Abakaliki from January 2001 to December 2011.

RESULT

There were 63 patients studied and stump wound infection was a complication in 38 (60 %) of them. Stump wound infection rate significantly correlated with the form of amputation, i.e., a higher rate in crushing than guillotine (sharp clear-cut) amputation (80.5 vs. 22.7 % p < 0.000); severity, i.e., a higher rate in major than minor amputation (80.6 vs. 33.3 % p < 0.000); and limb involvement, i.e., a higher rate in lower than upper extremity amputation (71.1 vs. 60.7 % p < 0.002). Haematocrit level on admission (p < 0.002), injury to hospital admission interval (p < 0.012) and injury to first surgical debridement / amputation interval (p < 0.02) were all significantly related to incidence of wound infection. Multivariate analysis identified crushing amputation as an independent risk factor (p < 0.009) for traumatic amputation stump wound infection.

CONCLUSION

The only independent predictor of traumatic extremity amputation stump wound infection is a crushing form of amputation; it should be accorded a high priority in interventions aimed at reducing infection rate.