Haiti's new amputees fear for their future ability to work

From the St. Louis Post-Dispatch:

LEOGANE, Haiti - Dr. Shane Hollawell bent over the operating table, scalpel in hand, and began removing the foot of 1-year-old Beverly Petchon, still wearing her pretty white dress.

Beverly was sleeping in a bed when the devastating earthquake struck Port-au-Prince on Jan. 12. A wall had collapsed on her. More than two weeks later, she was finally getting medical care. Such delays are all-too common as relief workers struggle to reach the wounded.

And many of the wounded are losing a limb.

In surgical scrubs and a sweat-stained golf hat with sun glasses perched on the bill, Hollawell could see that Beverly's mangled foot had to be cut away; otherwise, she could suffer infection. The New Jersey orthopedist tried to remove as little as possible, knowing that the more he saved, the better the chance she would have making it in a harsh country that can be so physically demanding.

"If we save (part of) their limb, we may save their life," Hollawell said of the amputees.

The 7.0-magnitude earthquake killed an estimated 200,000 people, injured 250,000 and left 1.5 million homeless. So far, there's no reliable count of how many Haitians have lost an arm or leg. Estimates vary widely on the final tally, some predicting tens of thousands.

But if the pace of amputations performed by volunteer American doctors at a small, makeshift hospital in Leogane is any indication, the numbers could be staggering.

Doctors worry that many amputees will suffer complications without proper rehabilitative care, exasperating an almost nonexistent public health system. And there's growing anxiety that the amputees will create a large class of disabled citizens who must try to survive in a beleaguered economy based on manual labor.

"Instead of producing goods, services and industry, now they're a drain," said Dr. Chris Buresh, an Iowa City pediatrician and emergency medical specialist. "It's just one more thing that beats them down."

The earthquake caused widespread destruction in a country where many homes and buildings are made of cinder block or minimally reinforced concrete. Some of the worst damage occurred in Leogane, a port city about 18 miles west of Port-au-Prince, where 80 to 90 percent of buildings were damaged, and military officials estimate 20,000 to 30,000 perished.

When the walls and roofs collapsed, many were pinned in the rubble, their limbs crushed. The wounds, filled with dirt and debris, soon became infected.

"We've taken rocks out of these open wounds, even after they were cleaned by doctors," said Dr. Dave Polonet, a New Jersey orthopedic surgeon.

Many of the injured who swamped the hospital in Leogane were found by Marines and roving truckloads of doctors who drove through remote villages and the tent cities and refugee camps that have sprung up amid the debris.

Some of the worst injured are being airlifted to U.S. Navy ships where additional amputations are being performed. Doctors continue to see patients with serious wounds that have yet to be treated. Many had no idea where to go or were too poor to pay for transportation to a hospital.

"They don't have a lot of options," said Dr. Greg Blackmon, a Knoxville pediatrician, who had spent several days working at the Leogane hospital. "In some cases they believe that if they just lay there at home, God will fix it."

Others told medical workers they had avoided going to clinics because they feared doctors were anxious to amputate. "It's a difficult country," said Martha Desir, a Haitian nurse at the hospital. "If you can't walk, you can't do anything."

Many prefer death to disability. Some have walked away from the hospital, despite warnings from doctors that infection could kill them.

"They don't want to be a burden to their family," Polonet said. "You have to make a hard sell to get them to agree to an amputation."

Back at the hospital, walking wounded continued to flood in.

Outside, patients waited beneath tarps under a hot sun. Many wailed in pain as doctors, dripping with sweat, tried to assess their condition on desks converted into makeshift examining tables. Chairs served as stretchers. Inside, doctors and nurses scurried down the crowded hallway of a converted dormitory, ducking into operating and recovery rooms to tend to the most critically injured.

"Organized chaos," said Dr. Jeff Mullholland, a Pittsburgh orthopedic surgeon.

In one operating room, doctors tried to save the right leg of Carole Plesime, 40, who had suffered a compound fracture the day of the earthquake, but waited two weeks to seek treatment.

On her initial visit, doctors cleaned the wound. They told the woman, who had a 3-week-old baby, that amputation was in order. Polonet recalled how strongly she resisted.

"No way," she told him. "I have a young family. How will they survive?"

So on this day, Polonet did something he said is almost unthinkable in a U.S. hospital. He closed the wound despite the high chance of infection. "She wanted us to try this first."

Still, he expects her to eventually lose the limb.

Joseph Valjal, 33, pleaded with his wife, Police Minoeche, 26, to follow doctors' recommendation to amputate a bit more of her left foot. If not, she risked losing the entire leg. She finally relented.

As they waited for the anesthesia to wear off, she lay stretched across three chairs, her head cradled in her husband's lap. He gently brushed her arm and stroked her cheek. The two left on the back of a scooter.

Many of the injured are subsistence farmers, able to grow only enough to feed their families.

"If he's sick or injured and can't get his crop in, his family starves," said Buresh, the Iowa City doctor.

Charles Henri, a pencil-thin 67-year-old with sunken cheeks, waited for a follow-up visit with doctors. He was missing his left arm below the elbow, injured when his house collapsed. Through an interpreter he told a doctor he was in pain, but feeling better.

Henri farmed rented ground. Now he feared losing the land. He hoped he might find someone else to take over the chores and pay him a few dollars on which to survive. For now, he is living in a shelter pieced together with plastic, blankets, tin and other scrap materials. Such temporary dwellings have sprouted in the streets like mushrooms. Neighbors gave him food.

"I'm scared I'm going to die," he said. "I can't find anything to eat."

In the U.S., amputees can spend several days in the hospital, receiving antibiotics and pain medication. Not in Leogane.

"We give them a pile of pills and send them home the day of surgery," said Josh White, an emergency room doctor from Minneapolis. "And before we got a better supply, that pile of pills was Tylenol."

Already confronted with a lack of doctors, many of the American surgeons said they were working hard to teach the Haitian nurses at the hospital how to wrap bandages and apply casts.

"Because that's who's going to be treating people after we leave," Polonet said

Several aid organizations are gearing up for the expected wave of amputees.

Physical therapists are nearly nonexistent in Haiti, as are prosthetics and those who know how to make and fit them. Even crutches are in short supply.

The Medical Benevolence Foundation, the Houston-based health care component of Presbyterian Church USA, is flying in walkers, crutches, and orthopedic hardware, such as nails, plates and screws to address short-term needs.

The agency, which has operated in the Leogane area since the 1970s, also is making long-term plans that could include training locals in the manufacture and fitting of prosthetics and construction of a rehabilitation institute, said Dr. Chip Lambert of Pittsburgh.

Buresh, the Iowa City doctor, has worked for years in Haiti. He returned shortly after the earthquake to help set up the Leogane hospital. He advocates a comprehensive approach to the amputee problem, including the creation of an improved education system.

"If you're missing a limb and have an education, you can still get a job doing office work or something where you're required to use your mind," Buresh said.

But if you don't have a good education, he said, you don't have a much of a chance. "If we don't take this opportunity, it means these people suffered and died for nothing. It's an opportunity to do it right."

As her baby lay wrapped in a blanket on the concrete floor of the recovery room, Beverly's mother waited outside on a sidewalk. The little girl, who also had a broken jaw and pneumonia, would stay overnight and receive antibiotics and pain killers. She would later be airlifted to the U.S. Navy ship Mercy for further treatment.

Maria Lee said she was happy the doctors had saved her daughter's life.

After the surgery, Hollawell stood outside in the fresh air. He was exhausted. He thought it must be past 5 p.m. and was surprised to learn it was just after 1 p.m.

He has performed about a dozen amputations in just the handful of days he has been here. And there's no end in sight. "It is what it is," he said finally.

With that, he trudged back inside. Patients were waiting.