“I was only distracted for a moment but my arm was already crushed,” says nine-year-old Derlens. After an accident involving a bread-making machine, he was taken to MSF’s Surgical and Trauma Emergency Center in Tabarre, Haiti, where he was given comprehensive care during two months of hospitalization. “After the accident I was very scared. I thought I was going to lose my hand. But now I’m healed and I find I can rely on my hand again,” says Derlens, who has regained most of the function in his hand.
MSF’s Surgical and Trauma Emergency Center in Tabarre is a specialized center built in 2012 in the aftermath of the 2010 earthquake. The center provides comprehensive trauma care, including emergency department services, operating theaters, inpatient and outpatient care, physiotherapy, mental health support, and social services, to people living in the urban commune of Tabarre. Due to road traffic accidents, armed gang clashes, and robberies, Port-au-Prince has high rates of both accidental and violent trauma, and many patients present with severe injuries and complex fractures.
Fractures or dislocations of bones in a patient’s legs or arms can generally be treated by internal and external fixation. Internal fixation places implants, such as metal screws, nails, or plates, into a bone to fix the fracture and allow it to heal. External fixation is used to treat open and complex fractures. When treatment is delayed, these have a higher risk of being infected. This process consists of inserting pins into the healthy bone through the skin and supporting these pins with a rigid external frame to bridge the fracture and stabilize the broken bone. Since 2012, the Tabarre Trauma Center has performed more than 8,500 orthopedic surgeries, with over 3,000 employing external fixation and more than 5,000 using internal fixation.
In 2019, MSF’s operations in Tabarre are planning to come to a close, and local health institutions will take over the provision of trauma care. To document MSF’s pioneering work in providing internal and external fixation in a low-resource, humanitarian setting, an operational research study was conducted. Its findings show the difference that MSF’s surgical and trauma care program made for trauma patients who underwent orthopedic surgery, and how lessons learned from Tabarre can be applied to similar humanitarian settings around the world.
Data of over 150 patients was collected and analyzed between 2016 and 2017, recording treatment methods and outcomes following external fixation surgeries. Although the majority of trauma victims arrived at the emergency department with a delay, most patients were operated upon arrival day or the day after. The majority of patients had injuries in the most serious category of open fractures, but amputation only had to be performed for six patients and only one patient died during the operation due to multiple severe injuries. Given the severity and complexity of the injuries, as well as the challenging context, these mortality and amputation rates can be considered low.
Thanks to effective prevention and control of infections, as well as rigorous clinical procedures such as wound washing, only a small percentage of patients developed infections of their wounds. Patients were also offered physiotherapy, and many experienced improved limb function and a decrease in pain, demonstrating the positive value of early post-surgery rehabilitation measures in Tabarre.
The promising evidence from MSF’s surgical approach in Tabarre demonstrates the feasibility of accomplishing challenging surgeries and providing quality trauma care in a resource-poor setting affected by urban violence. Thanks to its residency program, the Surgical and Emergency Trauma Center has also trained national general and orthopedic surgeons.
Designed to be a temporary institution, MSF’s Tabarre Surgical and Emergency Trauma Center will be closing its doors in mid-2019. Its legacy includes the successful treatment of thousands of patients, the reassurance of families, as well as the training of doctors and surgeons who will continue to care for patients in Port-au-Prince.
Header picture: MSF has been performing orthopedic surgeries and providing comprehensive trauma care at its Surgical and Trauma Emergency Center in Tabarre, Port-au-Prince, Haiti since 2012. © Christophe Hebting/MSF