Medical Care During Major Disasters

[Broomstick]

Although Haiti is in the news, what I wants to discuss here is really connected to ethics, technology, and reality which seems more suited to SLAM. The topic: Medicine in true disaster areas vs. medicine in the industrialized world. What follows are three recently published pieces on medical care in post-earthquake Haiti. In order to keep the length of this post under control I will not quote full articles, but rather excerpts. I will also chop this up into three posts so quoting won't be so burdensome. The links are to the full articles. I have also added comments of my own.

Doctors: Haiti medical situation shameful

Editor's note: Dr. Dean G. Lorich is the associate director of the Orthopaedic Trauma Service at the Hospital for Special Surgery and New York Presbyterian Hospital and teaches orthopedic surgery at the Weill Medical College of Cornell University. Dr. Soumitra Eachempati is a medical researcher with a clinical surgical practice and teaches at Weill Cornell Medical College. Dr. David L. Helfet is professor of orthopedic surgery at Weill Cornell Medical College and director of the Orthopaedic Trauma Service at the Hospital for Special Surgery and New York-Presbyterian Hospital.

New York City (CNN) -- Four years ago, the devastating Hurricane Katrina affected millions in the United States. The initial medical response was ill-equipped, understaffed, poorly coordinated and delayed. Criticism was fierce.

The response to Haiti has been the same. The point no one seems to remember is this: Medical response to these situations cannot be delayed. Immediate access to emergency equipment is also crucial.

Within 24 hours of the earthquake, Dr. David Helfet put together a 13-member team of surgeons, anesthesiologists and operating room nurses, with a massive amount of orthopedic operating room equipment, ready to be flown directly to Port-au-Prince on a private plane.

We also had a plan to replace physicians and equipment -- within 24 hours, we could bring in whatever was necessary on a private jet. We believe we had a reasonably comprehensive orthopedic trauma service; as trauma surgeons, we planned to provide acute care in the midst of an orthopedic disaster.

Remember - these doctors practice medicine in New York City, in one of the most technologically advanced nations on Earth, in a wealthy nation with intact infrastructure. I don't think they were truly prepared for what they encountered simply because they have entrenched assumptions due to the environment in which they have always worked. For example - their access to a private jet is fantastic, but I see no indication they had any clue about how overloaded the Port-au-Prince airport would be and its impact on resupply and transportation. (small airports in the New York City area typically have greater capacity than Port-au-Prince, this undoubtably skews perceptions on the part of those accumstomed to more developed nations)

We expected many amputations. But we thought we could save limbs that were salvageable, particularly those of children. We recognized that in an underdeveloped country, a limb amputation may be a death sentence. It does not have to be so.

A laudable sentiment, but while an amputation doesn't have to be a death sentence it still, most regretably, is in some places in the world.

We thought our plan was a good one, but we soon learned we were incredibly naive.

The bolded text says it all, really.

That Saturday morning slot also was canceled and postponed until the afternoon. The airport had one runway and hundreds of planes trying to land. But nobody was prioritizing the flights.

This seems to be a common complaint on the part of doctors and aid agencies, yet the Haitian government and the US supplied air traffic control both maintain that, in fact, flights were prioritized. The problem is, of course, trying to put 50 kilos of stuff into a 10 kilo sack - it just won't happen. Pre-quake, Haiti's main airport handled 30 flights a day. Now it's up to 160-180. Contrast that with New York's JFK, at 352 flights on a typical day. In addition, New York City is also served by LaGuardia, also in the city, and Newark in New Jersey. In addition, there are several additional, general aviation airports nearby, all of them with greater capacity than Toussaint Louverture Airport in Port-au-Prince. We're looking here at doctors accustomed to some the greater air travel capacity in the world being nearby suddenly landing in a place with, in comparison, woefully inadequate facitilies that are, on top of all that, severely damaged. So you have a number of flights wanting in that, frankly, would strain even New York's aviation capacity all funneling into a damaged airport with one runway, no taxiways, no refueling capacity... It seems to me that, even if you permitted ONLY medical aid flights, you STILL couldn't get everyone in who wanted in on a given day. That's no one's "fault", it's just harsh reality. Of course, every effort should be made to mitigate that reality, but reality it is.

Once we finally landed, we were taken to the General Hospital in Port-au-Prince with our medical supplies. We had been told that this hospital was up and running with two functioning operating rooms.

Once we arrived, we saw a severely damaged hospital with no running water and only limited electrical power, supplied by a generator. Surgeries were being performed in the equivalent of a large storage closet, where amputations were performed with hacksaws.

This facility could not nearly accommodate our equipment nor our expertise to treat the volume of injuries we saw.

As I said - they were naive. Yes, there were functional operating rooms, in that operations were being conducted in said rooms. The problem is, you can't wait for running water and power to be restored in such cirucmstances, people need care NOW. Bringing equipment that can't be used (because it requires resources that are not available) is not helpful. Absolutely, it was brought with good intentions and there certainly was a lack of communication here (which is a feature of major disasters, so the not-naive should anticipate such things), but on a certain level extra hacksaws, some anesthetics that don't require elaborate equipment, and lots of painkiller would have been much more helpful than technology that wasn't usable.

We quickly took our second option: Community Hospital of Haiti, about two miles away. There, we found about 750 patients lying on the floor. But the facility had running water, electricity and two functional operating rooms.

I applaud their resourcefulness in finding facilities where they and their equipment would be of more use.

We found scores of patients with pus dripping out of open extremity fractures and crush injuries. Some wounds were already ridden with maggots.

About a third of these victims were children. The entire hospital smelled of infected, rotting limbs and death. Later on, we would judge our surgical progress by the diminishment of the stench.

This is known as "civil war medicine" in the US, as it's essentially what was available in 1860.

In our naïveté, we didn't expect that the two anesthesia machines would not work; that there would be only one cautery available in the entire hospital to stop bleeding; that an operating room sterilizer fit only instruments the size of a cigar box; that there would be no sterile saline, no functioning fluoroscopy machine, no blood for transfusions, no ability to do lab work; and the only local staff was a ragtag group of voluntary health providers who, like us, had made it there on their own.

Again, it's a problem that modern technology is not compatible with circumstances that don't have reliable electricity. Better to bring less equipment needing power and pack sterile saline. It also shows why doctors in Haiti have been using vodka to sterilize equipment - lack of clean water, lack of autoclaves, lack of power for autoclaves...

As we got up and running and organized the patients for surgery, we told our contacts in the United States what we needed. More supplies were loaded for a second trip. Those included a battery-operated pulse lavage, a huge supply of sterile saline and the soft goods we needed desperately in the operating room.

While it would have been better if this had been their first load of supplies, let's give them credit for learning quickly and taking action.

The plane landed as planned Sunday night, and the new equipment was loaded onto a truck. Then that truck, loaded with life-saving equipment, was hijacked somewhere between the airport and the hospital.

And THAT is precisely why there must be military during aid operations of this sort. The doctors quickly learned that that list were the truly valuable medical supplies. Naturally, some less ethical/honest people will realize that, too. It may have even been appropriated by some other medical group, for all we know, or sold to another medical group. One can hope it went to someone who actually needed it, but of course diversion of such supplies is a serious problem under such circumstances.

We were unprepared for what we saw in Haiti -- the vast amount of human devastation, the complete lack of medical infrastructure, the lack of support from the Haitian medical community, the lack of organization on the ground.

And that is why it's problematic for amateurs to rush into help - and while they were professional doctors they were amateur aid workers. Expertise in one area does not translate into expertise in all areas or under all conditions.

No one was in charge. We had the first hospital in the Port-au-Prince area with functioning operating rooms, yet no one came to the hospital to assess how we did it or offer help.

And this man is still naive - clearly, all the other people on the ground were also just as desparately trying to render aid, were just as undersupplied, overworked, and exhausted.

The fact that the military could not or would not protect the critical resupply medical equipment on Sunday, or allow the Tuesday flight to come in, is devastating and merits intense investigation.

There was no security at the hospital. We needed a much higher level of security with strong and clear support of the military from the very beginning.

What are they expecting to find? Seriously? The airport is a bottleneck, pure and simple, and isn't going to be fixed to anyone's satisfaction for a long time.

They want more medical flights, more security (which also has to come in by air), but don't seem to understand that the one airport has extremely limited capacity. It is, again, no one's fault, it's just bitter reality.

The lack of support for our operation by the United States is shocking and embarrassing and shows how woefully unprepared we are for the realities of disasters.

What, exactly, do they want in the way of support? The US (in cooperation with others) is keeping the airport open, bringing in security and supplies, and so on. The US send a freakin' floating' 1000 bed hospital and an aircraft carrier.

Are they upset that it was Jamaican soldiers that escorted them out of Port-au-Prince rather than Americans? I'm sorry, it's an international relief operation, and I"m certain Jamaican soldiers are just as capable as US soldiers of providing the needed security in such circumstances. Actually, I don't know that that is the problem, but I wonder if it might be. What should it matter what the nationality of people providing security is, as long as they provide what is needed?

We first thought we would support those at the helm but soon realized we were almost the only early responders with the critical expertise and equipment to treat an orthopedic disaster such as this.

Still, nobody with a clear plan is in charge, and care is chaotic at best. Doctors are coming into the country with no plan of what they are going to do, and nobody directing them how to do it.

It seems to me that lack of a clear chain of command is a feature of such major disasters. Perhaps those wishing to help should be told that explicitly - except, of course, there is no one to coordinate such a message.

Surgeons who expect to show up and operate will be mistaken. Without a complement of support staff and supplies, they are of limited to no value.

And let that be a lesson to prima donnas - you can't simply ride in, perform as usual, and ride off into the sunset on your white horse as the hero. This is one reason why using military medical assets makes some sense in these circumstances. A national military such as the US or Israel has units that can transport the entire infrastructure needed for an aid station or field hospital (the Israelis, in particular, had a fantastic field hospital set up in Haiti), the whole thing top to bottom from high tech equipment down to the smallest bandages.

[quote\]We left feeling as if we abandoned these patients, the country and its people, and we feel terrible.[/quote]
And here I feel they are too harsh on themselves. They did get in over their head, but they didn't turn and flee immediately, they stayed and did their best. They might have saved some lives, at least they tried.

Our role back in New York is to expose the inadequacies of the system in the hopes of effecting change immediately. Patients who are alive and still have their arms and legs remain in jeopardy unless an urgent response is implemented.

And here we go again - you will not get immediate change for Haiti. The best that can happen is that we learn from this disaster and apply it to the next disaster IF that is even possible. Aid agencies do learn from their experiences in such circumstances and do make changes. This has made real improvements in handling such mass-casualty, wide-scale disasters but, again, the harsh reality is people ARE going to die, people who might, under other circumstances, have been easily saved. Again, all the more reason to try and try harder, but realistically there will be a lot of tragic death and mutilation. That's why it's a disaster.

Upon our departure, we witnessed pallets of Cheerios and dry goods sitting on the tarmac helping nobody. Yet our flight of critical medical equipment and personnel had been canceled, and the equipment that did get through was hijacked.

So... what is he proposing? Don't bring in food, just bring in medical equipment? There are a myriad of competing interests involved here - people need water AND food AND medical care AND security AND shelter... and they are all needed yesterday. For all this doctor knows those pallets of food and dry goods went somewhere they were desparately needed and half an hour after these doctors left.

We implore an official organization to step up and take charge of the massive ongoing medical effort that will be necessary to care for the people of Haiti and their children. And to do it now.

The problem is that in such a disaster as this the "official organizaton" that would normally take charge - the Haitian government - is out of commission or barely functional. That leaves the problem of who should step in - the UN? The US? Some sort of coalition? (Oh, yeah - that last one isn't going to happen very quick).

[Broomstick]

Hard lessons, humility for big-city doctors in Haiti

The doctors, who worked at the Boston Medical Center, quickly learned that when you have no technology -- not even the simplest blood test -- you have to make medical decisions in an entirely different way.

The first death they witnessed taught them a valuable lesson.

The patient was a boy who needed his leg amputated or else he would die of either an infection or rhabdomyolysis, a kidney disease that follows injuries where muscles are crushed.

Feliz, Georges and the other doctors had nowhere to take the boy. Their own hospital had yet to open its operating room, so they spent hours trying to find a hospital that could do surgeries. Their search was in vain.

Finally, the doctors decided to do the surgery themselves that night by the moonlight under a mango tree.

"We just sawed his foot off. We didn't have to use anesthesia because he was already unconscious and wasn't feeling a thing," Feliz says.

But they'd waited too long. The boy took his last breath during the surgery.

I used to work for someone, a medical doctor, who used to say you should not discard the good in search of the perfect. Sometimes you can't wait for perfect, sometimes not even for good, sometimes you have to do what needs to be done in far from ideal circumstances.

As a direct result of the boy's death, a few hours later, at 3 in the morning, the surgeons at the University of Miami hospital decided to build their own operating room. They had no surgical lights, no oxygen, no blood, no ventilators and no monitors. For a tourniquet they used one of the doctor's belts.

"We'd been waiting to build the operating room until we received better equipment, but after that boy's death we became more aggressive. We said let's do it, because they're going to die anyway," Feliz says.

And that is a hard but valuable lesson - ordinarially, amputating with a hacksaw, without anesthesia, would be an egregious violation of medical ethics but under some circumstances it is the right and moral thing to do. It's still terrible, so consider it the lesser of several evils.

The doctors continued to learn lessons about what one had called "civil war medicine" after the operating room went up.

"Civil war medicine" refers to the medicine of around 1860, the time of the US Civil War. Except I think most civil war battlefield doctors had more painkillers than are currently avaiable in Haiti due to shortages.

At one point, a 16-year-old boy needed an amputation, but the surgeons asked Feliz and Georges to make sure the boy's kidneys were working before they put him through surgery. Without any blood tests to assess kidney function, the only thing they could look for was urine as a sign that his kidneys were working.

"We tried to see if we could get some urine going, but there was not a drop. We filled him with fluids and gave him Lasix, a diuretic, to get him to pee, but nothing," Feliz says.

The boy died as the doctors were treating him.

And this gets into diagnosis without modern technology, and triage. "Are his kidneys working?" becomes "Can he pee?". In a different place someone with acute kidney failure might be saved, but right now in Port-au-Prince it's a death sentence. You can't afford to waste medical resources (beyond compasionate care) on someone who will certainly die, nor is it a kindness to subject someone to useless surgery.

"Back in Boston, I'm a hot shot. The nurses have to respect me," Feliz says. "Here, I'm just a worker bee. I cleaned the OR floor after surgery. I carried dead bodies down the street. I was in traffic carrying dead bodies. That makes you human. I came here a very fancy doctor, and I'm leaving here as a humble man."

And that's the thing - in such a disaster area you can't be just the star doctor, you have to be able to do everything that must be done to make things work.

[Broomstick]

Haiti's 'floating hospital': Tough questions on USNS Comfort This page has links to other articles and videos that may be of interest

By Steve Sternberg, USA TODAY
ABOARD THE USNS COMFORT — Yvelot Brianville, 24, lies quietly on a steel hospital gurney, a boyish naval officer in blue combat fatigues standing by his side.

The officer, Lt. Cmdr. Mill Etienne, 34, is Haitian, fluent in Creole. He is also a neurologist, called to the intensive-care ward of this floating U.S. Navy hospital just off the coast of Port-au-Prince to assess the impact of Haiti's earthquake on one man's spine.

This points out two things about the Haitians as a group: as Lt. Cmdr. Etienne demonstrates there are certainly smart, capable Haitians and given a chance and a decent environment they can be very successful. There are also quite a few Haitians who are US citizens, serve in the military, and are now serving during this aid operation. Most of them are working as translators, in addition to whatever else they normally do.

Etienne has been on active duty in the Navy just six months. But since he boarded the Comfort, which set out from Baltimore Jan. 15, he has become a confidant and emissary of the commanding officer.

He has helped create a phonetic medical phrase book so doctors can ask their patients simple questions in Creole. He also has been named chairman of the ship's medical ethics committee.

"When he came aboard he was a neurologist with a special interest in ethics and cultural awareness," Ware says. "He's become a trusted adviser and representative for the U.S. Navy."

A native of Haiti, he left the island just a few days before his sixth birthday, when his family fled the bloody regime of Jean-Claude "Baby Doc" Duvalier in 1981.

And moving out of Haiti made all the difference, really - that's the major thing separating Lt. Cmdr Etienne from the poor, uneducated Haitians of Port-au-Prince. Etienne moved to a place where he could get the basic necessities of life - food, clothing, shelter - AND an education.

"I joined the Navy not to serve Haiti but to serve the United States," he says. "It's an interesting irony that I can serve both in one mission."

I had a 12-year-old whose whole family was crushed. A little boy was sobbing on his gurney. I asked him what was wrong, and he said, 'I want to go home. I want to see my family.'

"He has no family. He has no home. It's all gone."

"I had to amputate a guy's foot today," Donahue said Monday. "He's a policeman in Port-au-Prince. He's got four kids. He had gas gangrene. He said, 'How am I going to support my children?'

"If I don't (amputate)," Donahue told the patient, "you'll die today or tomorrow."

On Sunday night, a 23-year-old woman decided that rather than have a futile operation, she would die. She had been crushed by a falling pole when she lunged into the street to save a child. She asked doctors if she could die peacefully on the Comfort, with her mother, who lives in Port-au-Prince, by her side. Etienne arranged for her mother's flight.

There were the young man with cerebral malaria and three patients with tetanus, which Etienne says he has never seen before. None is expected to survive.

The goddamn shame of it all is that tentanus is preventable - but clearly, for lack of vaccination three people on the Comfort will die. Again, that is the difference between the developed world, which takes clean water and tetanus vaccine for granted, and a place like Haiti.

In a case that divided the medical staff, Etienne was called in to consult on an 11-month-old boy whose head is so swollen with hydrocephalus — a blockage that prevents spinal fluid from draining — that Etienne had to stick two paper tape measures together to gauge its circumference.

The boy's case provoked a furious debate among doctors, already stretched to the limits of exhaustion and resources. Should they perform brain surgery to put in a shunt and tubing that would let the fluid drain into his abdomen?

Or should they focus instead on patients injured in the earthquake and not roll the dice on what might be a temporary fix for a fatal condition?

"Personally, I would treat him. We have the shunts. We have the tubing," says Cmdr. Dennis Rivet, a neurosurgeon, noting that the operation is done with success in poor African countries.

"I would set him free with a blessing," counters Capt. Arne Anderson, a pediatrician. He notes that many shunts eventually fail.

He also says the Ministry of Health of Haiti had asked the Comfort not to provide medical care that can't be sustained in Haiti.

"He'll die," Rivet says.

"If you like the risks, and the risks are small, I'll support you," Anderson says.

The doctors agree to wait for a CT scan to decide. If the boy's brain shows no damage, surgery might become a reasonable option.

Etienne says the case offers a perfect reflection of the crossroads Haiti has reached. If the earthquake had not happened, he says, "the kid would never have left the house. The family would have hidden him away. Because the earthquake wrecked their house, the family can't hide him any longer."

I think there's a lot of room for a lively discussion on that case. What are the ethics of withholding medical that "can't be sustained"?

[Lusankya]

I think there's a lot of room for a lively discussion on that case. What are the ethics of withholding medical that "can't be sustained"?

I say give it to them, as long as it doesn't divert resources from those who need it more urgently. In a poor country like Haiti, insulin for diabetics or medication for other chronic conditions would be another kind of medical aid that "can't be sustained", depending on the resources of the person who needs it, but withholding that seems quite ridiculous. The only real difference between providing medication for a long-term condition and providing surgery for a long-term condition is that the latter uses up more resources. That would be cause for making the latter a lower-priority case than the former, but not a cause for just ignoring it.



I was actually thinking something somewhat related to this recently: if developed countries created a law that read something along the lines of (for example) "Australian companies that invest in other countries must still comply with Australian environmental, construction and safety standards" then it would provide some benefit in disasters like this, because even without local building standards, there would still be some buildings that would (hopefully) be well-built enough to withstand the disaster. Having surviving infrastructure would be a huge boost to relief efforts.

[Broomstick]

I think there's a lot of room for a lively discussion on that case. What are the ethics of withholding medical that "can't be sustained"?

I say give it to them, as long as it doesn't divert resources from those who need it more urgently. In a poor country like Haiti, insulin for diabetics or medication for other chronic conditions would be another kind of medical aid that "can't be sustained", depending on the resources of the person who needs it, but withholding that seems quite ridiculous. The only real difference between providing medication for a long-term condition and providing surgery for a long-term condition is that the latter uses up more resources. That would be cause for making the latter a lower-priority case than the former, but not a cause for just ignoring it.

The thing is, a child with hydrocephalus might well need much more than just surgery - mental retardation does not always occur, but it's a common side effect as is any manner of other neurological defects such as paralysis or sensory impairment.

So - definitely the child needs a shunt for cerebro-spinal fluid, without it, the brain will eventually be wrecked and the child will die. This can take years, though.

The child may require, in addition, supportive services for other handicaps.

Shunts do, eventually fail (usually) which would require additional surgery unlikely to be obtained by a poor Haitian slum-dweller.

Clearly, the doctors are investigating whether this is brain damage at this point, and if so, how much. People with hydrocephalus and some brain damage have gone on to live fairly normal lives with normal (or even above-normal) intelligence though that's a little uncommon. Let's look at a couple scenarios:

1) The child's brain is not significantly damaged. Should the doctors proceed with surgery, knowing that there is a likelihood that 10 or 15 years down the line (perhaps even much sooner) the shunt will fail, and pressure will once again build in the child's skull, almost certainly causing disability and death without a new surgery? Is it right to give this child surgery, granting some more quality years, knowing that there is a likelihood of early death?

2) The child's brain is significantly damaged. The child has physical and cognitive defects. Should surgery be performed anyway? Does it make a difference if the child is orphaned (thus, without caretakers) or not?

3) Should the doctors leave well enough alone, in other words, maintain the status quo? No surgery in this case. Well, someone has been feeding and caring for this child, who is no longer an infant. Under pre-quake circumstances the child was essentially facing a terminal illness and was in at-home hospice care of sorts, being (presumably) kept comfortable as his disorder ran its course. It's probably what happens to most very poor Haitian children born with severe birth defects. Is it kindest to invoke a medical "Prime Directive" of sorts and simply not interfere?

[Simon_Jester]

If the child does not have severe brain damage, I'd say perform the surgery, though as a low priority on a triage list. There are sure to be other patients who need treatment more urgently, and the child probably won't die immediately if not treated (whereas people with gangrenous limbs or internal bleeding will).

If the child does have severe brain damage, there's a major quality of life issue that complicates the situation. Given the overall scale of the disaster, I'd say that the child would be so low on a triage list that the surgery probably shouldn't be done at all; there isn't time.

[Lusankya]

1) The child's brain is not significantly damaged. Should the doctors proceed with surgery, knowing that there is a likelihood that 10 or 15 years down the line (perhaps even much sooner) the shunt will fail, and pressure will once again build in the child's skull, almost certainly causing disability and death without a new surgery? Is it right to give this child surgery, granting some more quality years, knowing that there is a likelihood of early death?

Is it right to give this child surgery, granting some more quality years

Why are you even asking this question?

2) The child's brain is significantly damaged. The child has physical and cognitive defects. Should surgery be performed anyway? Does it make a difference if the child is orphaned (thus, without caretakers) or not?

These are issues that would complicate the decision as they may result in the child's additional years not being quality years.

3) Should the doctors leave well enough alone, in other words, maintain the status quo? No surgery in this case. Well, someone has been feeding and caring for this child, who is no longer an infant. Under pre-quake circumstances the child was essentially facing a terminal illness and was in at-home hospice care of sorts, being (presumably) kept comfortable as his disorder ran its course. It's probably what happens to most very poor Haitian children born with severe birth defects. Is it kindest to invoke a medical "Prime Directive" of sorts and simply not interfere?

They're already interfering. And while "leave shit alone" is a decent rule of thumb, but giving disabled children surgery that may allow them to have some quality years of life ahead of them is not the kind of thing the Prime Directive was meant to prevent (unless you're watching Enterprise, but that doesn't count because it's shit).

As Jester said, the issue is one of triage, not of whether or not performing the surgery itself is actually moral.

[Broomstick]

1) The child's brain is not significantly damaged. Should the doctors proceed with surgery, knowing that there is a likelihood that 10 or 15 years down the line (perhaps even much sooner) the shunt will fail, and pressure will once again build in the child's skull, almost certainly causing disability and death without a new surgery? Is it right to give this child surgery, granting some more quality years, knowing that there is a likelihood of early death?

Is it right to give this child surgery, granting some more quality years

Why are you even asking this question?

Because I have heard people argue against life-saving surgery with the excuse "the child will only die before adulthood anyway". Because the Haitian government said "do not provide medical treatment that can't be sustained". Because there are limited resources on board the Comfort and people in danger of imminent death, not death months or years down the road.

While the decision to operate is obvious to you or me, it is not so to others, or in all circumstances.

2) The child's brain is significantly damaged. The child has physical and cognitive defects. Should surgery be performed anyway? Does it make a difference if the child is orphaned (thus, without caretakers) or not?

These are issues that would complicate the decision as they may result in the child's additional years not being quality years.

Don't forget - the child is going back to Haiti where there is no special education and no real help for the handicapped. A person who can't walk, for instance, is homebound and will find it near impossible to go to the store, church, work, or even to the next block over. If the child can't even get about on his own his life will likely be restricted to a single abode or even a single room. There is no support system for the handicapped.

3) Should the doctors leave well enough alone, in other words, maintain the status quo? No surgery in this case. Well, someone has been feeding and caring for this child, who is no longer an infant. Under pre-quake circumstances the child was essentially facing a terminal illness and was in at-home hospice care of sorts, being (presumably) kept comfortable as his disorder ran its course. It's probably what happens to most very poor Haitian children born with severe birth defects. Is it kindest to invoke a medical "Prime Directive" of sorts and simply not interfere?

They're already interfering.

That's a very good point.

And while "leave shit alone" is a decent rule of thumb, but giving disabled children surgery that may allow them to have some quality years of life ahead of them is not the kind of thing the Prime Directive was meant to prevent (unless you're watching Enterprise, but that doesn't count because it's shit).

And yet - there are people in the world who would argue exactly that. I find the attitude mystifying, but then I got silly and married someone disabled so obviously I am hopeless warped in these matters.

As Jester said, the issue is one of triage, not of whether or not performing the surgery itself is actually moral.[/quote]

[Mayabird]

I suppose another way of looking at it past the triage, if that's not a factor, is quality of life after surgery. If he could get a few happy years where he could laugh and play and so forth, it would be fine even if it wouldn't be much after that, but if he has no family or support structure left and this would basically mean dumping him in a destroyed country with no food or ways of caring for himself so all he could do would be beg or steal, if not drift into a criminal gang or get trafficked by one, or turn to sniffing glue or whatever the local substance of choice is, why bother? Although I suppose you could still look at it in a triage sense - I could save this one kid without parents or any relatives who'll just end up on the streets best case scenario, or I could save this other kid who still has a living mother and aunt who can take care of him.

[Simon_Jester]

Re: Mayabird: This kid has a family who were willing to care for him while his head swelled up and crushed his brain. Nothing I hear makes him think he's now an orphan. If he could be restored to a normal state of health with a shunt, then I see no reason to assume his prospects would be any worse than those of a normal Haitian 1-year-old child. Which are bad, but still better than being dead.

Because I have heard people argue against life-saving surgery with the excuse "the child will only die before adulthood anyway". Because the Haitian government said "do not provide medical treatment that can't be sustained". Because there are limited resources on board the Comfort and people in danger of imminent death, not death months or years down the road.

Which is why, as we say, it's a triage question. I don't know how packed Comfort's wards are; given my best guess of conditions, the hydrocephalic child should wait in line behind the people who are in greater danger of immediate death. That's the sort of thing that gets considered triage, right?

[Broomstick]

True. That is triage.

At this point, what I read this morning indicates that the Comfort, as well as other ships in the area, are at or near capacity. Construction has begun on a 5,000 bed tent hospital (that's five times the patient capacity of the Comfort, and an enormous hospital by any measure). The hope is that those recovering from surgery and in less severe condition could be transferred to the tent hospital on land, with the ship board facilities for the most severe cases and major surgery.

Let me point something out about the notion of a 5,000 bed hospital. From what I could find on-line, the largest current hospital in the world is Chris Hani Baragwanath Hospital, in South Africa with 3,500 beds. The proposal is to build one even larger than that in one of the poorest nations on Earth in a matter of weeks. And there's reason to believe that it will still not be enough to cover demand in just the Port-au-Prince area.