Tsunami

Like the “four horsemen of the acropolis”, the aftermath of the tsunami resembles a WWI battlefield. Wounds that were tolerable but poorly cared for are now becoming infected. Bad water and sanitation contribute to the problem and clostridium. Gangrene and lockjaw, rarely seen since tetanus shots and antibiotics emerge a week after the trauma in an unprotected population and a scarcity of antibiotics. Often too late for treatment, amputation becomes the only option, and that too may be done to late.

I did not consider myself lucky to be assigned an amputation as my first surgery when an intern on surgical service. I was briefed by an old WWI surgeon. He was generally considered over the hill, but when briefing me in the procedure he came alive with knowledge. He demonstrated the regional block, which worked perfectly and talked me through the procedure as my assistant with many small tricks. This information was unavailable anywhere else. The knowledge was live verbal history from the battlefield. I don’t remember any but the occasion now and am just as glad.

The drugstores and hospitals must have been wiped out with the floodwaters. People walking around wounded with cuts, lacerations, fractures and abrasions lacked clean water to even wash the wounds. Prophylactic antibiotics may not have been high on the list of disaster relief priorities. Fracture care and local wound care are first priorities with trauma surgeons. The emerging infections are not immediately evident. When they become so, it is often too late. The judgment of when to amputate is not an easy one. Such was the challenge of battlefield surgeons prior to sulfa and penicillin.

Once a deep tissue infection or an infection associated with a fracture gets established the required intravenous treatment with the kind of antibiotics required for these infections may lay beyond the capacity of the emergency field hospital. Unlike the clean but jagged battle wound, the tsunami wounds were washed by ocean, lake and river water and further contaminated by animal and sewer waste.

Amputation has become a lost art. In the field hospitals of WWI, amputation was elevated to a fine art, in exactly estimating its requirement, timing and execution. The procedure often preformed under local anesthesia, regional block, was routinely preformed in a matter of a few minutes---without power tools. Speed was of the essence. Those dealing with the present surgical crisis will be exceedingly challenged to adapt to the sepsis, the inconsistent availability of antibiotics, the surgical decisions and the primitive field conditions.