ARTICLE - AMPUTEES

The following is an article about the prosthetics work that is being done out in Deschapelles at the Hopital Albert Schweitzer. Hopefully this program will also be equipping Luciano with an artificial arm as well. Pray for the work of those who are providing prosthetics for amputees here in Haiti.

MENDING BODIES AND CHANGING ATTITUDES IN HAITI
(The Philadelphia Inquirer) - By Michael Matza

LASCAHOBAS - She awoke before dawn in the one-room shack she shares with four family members and began to dress.

She straightened the bandage on the stump of her left arm and donned a denim skirt and white sleeveless blouse.

She slipped on sandals and pink stud earrings.

Then she walked half a mile up the dirt road to the village center and squeezed into a cab for the jarring ride to get a new left arm.

"It's a big day for me," said Sonia Donatien, 32, anticipating the two-hour trip to the regional hospital where American prosthetists are mending victims of Haiti's earthquake. "I lost an arm. I am going to replace it."

Three months ago, Donatien's crushed arm was removed in a delicate operation by University of Pennsylvania Health System surgeons on a relief mission. Now, in a matter of hours, she would get the first prosthetic arm delivered in Haiti since the quake.

The Jan. 12 cataclysm devastated much of the country. It killed more than 230,000 people and left thousands of victims whose crushed or severed limbs had to be surgically removed.

Handicap International, the French medical group working with the World Health Organization and the Haitian government to coordinate amputee care, puts the number of amputees, including people who lost fingers or toes, at 2,000 to 4,000; other aid groups say the total is at least 6,000. Even before the quake, Haiti had an amputee population of about 80,000, almost none of whom had prosthetics.

In a shattered country where able-bodied people have trouble carrying buckets of water or squeezing through the stalls of jammed outdoor markets, amputees are especially vulnerable. The earthquake destroyed the country's only two prosthetics workshops.

Streets here teem with cars and pedestrians. Sidewalks are rare, let alone curb cuts, wheelchair ramps or handicap parking. Disabled people often are beggars and outcasts, derided as kokobe, Creole for "broken body," because they cannot find work.

"The stigma is strong," said psychologist Luana Forestal, a counselor for amputees at Haiti's Hospital Albert Schweitzer.

For that reason, the signature wound of the quake also has produced a broad effort by foreign volunteers, using donated materials and expert staff from overseas companies, to introduce first-world prosthetics, physical therapy and enlightened attitudes about public health.

These partners are rebuilding women and men torn apart by the quake's violence and ravaged by subsequent infections. But the long-term goal is to train local technicians and physical therapists to create a prosthetics industry that can be self-sustaining in Haiti, because patients who get prostheses now will need refitting throughout their lives.

Relief workers say it is too early for a precise breakdown of the injuries, although preliminary surveys indicate lost legs exceed lost arms nearly 6-1. Legs were particularly vulnerable because the tremors that knocked people to the ground left them prone and defenseless against falling debris.

Many lower-extremity amputees already have been fitted with temporary legs by the foreign volunteers and are learning to walk. The top priority is to make them ambulatory.

"The approach to rehab has to be tailored to the environment," said Col. Jennifer Menetrez, the U.S. Army's top surgeon in Haiti and a participant in the national commission roundtables on amputees. "Here, if you can't walk, you're done. Just try to use a walker or a wheelchair."

Working with the Army's Joint Task Force Haiti, Menetrez is assigned to Port-au-Prince through the end of June. She is director of the Center for the Intrepid at Fort Sam Houston in San Antonio, Texas, a rehabilitation facility for soldiers with severe war wounds, including amputations and burns.

Menetrez said about 1,000 U.S. soldiers had lost limbs in the wars in Iraq and Afghanistan; Haiti, by contrast, suffered about twice that number of amputations in the worst earthquake to hit the region in more than 200 years.

Prostheses for upper extremities are harder to fabricate because of the number and complexity of the joints involved. Depending on where an arm is severed, prosthetists may need to try to mimic the movements of a shoulder, elbow, wrist and fingers, all joints of complex and fluid movement. Even with the infusion of foreign expertise, Haiti lacks the capacity to build arms that mimic that range of motion.

Into that vacuum stepped the Hanger Orthopedic Group, a publicly traded manufacturer of orthotics and artificial limbs with 690 patient-care centers across the United States.

Like other prosthetic companies volunteering in Haiti, Hanger's initial concentration was on legs, and it fabricated more than 70 in its first three weeks on the ground. Because the human body is accustomed to balancing on two points, a provisional leg that provides basic support can be simpler to build, and easier for a patient to learn to use, than an arm.

But Hanger also took on the challenge of building Donatien's $8,000 arm at one of its branches in Lafayette, La., a squat, white stone building down the street from Cajun take-out joints, with exam rooms in front and a machine shop in the back.

Hanger donated Donatien's arm as part of a million-dollar relief contribution. Prosthetists at the company say they believe it is the first arm fitted in Haiti since the quake.

Antoine Engrand, chief of mission for Handicap International in Haiti, said he knew of no others.
A long way from Louisiana, in her dusty village that was spared by the earthquake, Donatien collected her thoughts on this morning in early April, ahead of what felt to her almost like an introduction. She would meet not a person, but a part of her body, a new arm. She said she was "happy" and "proud" to head the list.

"It is a grace from God," she said, setting out from her small farming and trading community.

"And by God's grace I lost just one arm. Some people lost arms and legs."

Three months have passed since those 35 seconds of tectonic terror. The three-story Port-au-Prince house where Donatien worked as a housekeeper was destroyed when its stone pillars gave way, causing floors and ceilings to pancake. Donatien, rail thin, was resting on a bed on the third floor when the roof fell in. She was buried in the rubble between the second and third floors for two days, her left forearm and hand crushed between concrete blocks.

Emilio Paris, 53, a cook in the house across the street, recalled how eventually he heard stirring and saw a figure covered in chunks of yellow-painted cinderblock and plaster dust.

"Sonia is not dead! Sonia is alive!" he remembered shouting to neighbors, six of whom joined him in her rescue. They yanked away rubble and dragged her out over crumbled concrete, which stripped skin from her back and shoulders.

With no place to go, Donatien, whose parents died when she was a child, spent uncomfortable nights in the courtyard of the undamaged house across the street. Like others who felt the aftershocks and feared more toppling, she was afraid to sleep indoors. By day she sought treatment at emergency clinics for her hand, which had turned black and had no feeling.

Overwhelmed aid workers checked for broken bones, found none, and advised her to see a surgeon - if she could find one.

A daughter of the family Donatien worked for gave her $45 in cab fare to get to the respected 105-bed hospital in Cange, a three-hour drive north of the capital and well beyond the damage zone centered in Port-au-Prince. It was a hospital Donatien knew well. Four years earlier her daughter, Soleikah, was born there.

The hospital, Zanmi Lasante, began 25 years ago as a church clinic and has expanded through its affiliation with the well-known Boston medical relief group Partners in Health.

The hospital held mixed memories for Donatien. Soleikah was born a twin. But five days later, while still in the hospital, her sister died. Donatien never named the child.

With her arm lying lifeless on her lap, the journey to the hospital aboard a truck mounted with bench seats was a painful ride. Hundreds of thousands of city dwellers whose houses were destroyed had begun an exodus to the provinces. Many rubble-heaped roads were impassable.

A trip that should have taken three hours took eight.

She was relieved, finally, to see the stone wall around Zanmi Lasante's campus. After an initial evaluation, she was admitted to the hospital, where hundreds of wounded lay on stretchers and mattresses on the floor.

"There was swelling, loss of sensation, and dead tissue on her fingers," said Fredly Petiote, the Haitian doctor who examined Donatien and recommended amputation before the likelihood of a massive infection put her life at risk.

Donatien was afraid, so doctors began with a conservative approach, a fasciectomy: slitting open the arm to cut away dead tissue before washing the wound and closing it. Although the procedure went smoothly, it did not produce improvement.

In a church chapel converted into a recovery area, Donatien was mulling her dreaded options when an accident of timing brought the most rarefied of medical expertise right to her bedside.
Her admission coincided with a relief mission by a nine-member team of doctors and nurses from the Hospital of the University of Pennsylvania Medical Center in late January. Wearing scrubs and draped with stethoscopes, they trooped toward her in the crowded church on their initial rounds.

Penn orthopedic surgeon Samir Mehta, a superconfident 34-year-old who a year earlier had repaired the broken hip of Vice President Joe Biden's 91-year-old mother, Catherine, explained to Donatien that the gangrene in her lower arm and hand could spread to her vital organs.

She faced a stark choice: lose the limb, or very likely lose her life. Fearing disability and disfigurement, Donatien hesitated again. But a day later, after concluding that God had spared her for a reason, she chose amputation. Mehta and his team removed the arm in a two-hour operation.

Right-handed, Donatien was relieved not to lose her writing hand. But in the recovery room still woozy from anesthesia she signed her name "Donassien," and it was reported that way in some early hospital records.

She was discharged from the hospital Feb. 14 and, with the surgical staples still in her stump, traveled an uncomfortable hour's drive on a rutted road to her native village, Lascahobas, to recuperate. She survived on handouts she got from an aunt in a nearby village.

Donatien moved into the cramped, tin-roof shack she shares now with her daughter and three grown cousins. Physical pain and depression about her future sabotaged her sleep.

One-armed, she could still cook on the open coal fire that is the household's only stove. She could bathe herself and her daughter in the nearby river. But other tasks, like braiding her hair, or washing laundry in the river, were suddenly beyond her. Occasionally, she had unnerving phantom sensations, like the urge to scratch an itch on a forearm that wasn't there.

Back in the United States, Hanger public relations director Jennifer Bittner read about Donatien's surgery in the Jan. 31 Philadelphia Inquirer and shared the story with the company's top executives. They stepped forward to help her through the Haitian Amputee Coalition, a joint effort they are heading to provide free prostheses for quake victims.

In March, Hanger sent an advance team with tons of equipment to build a state-of-the-art prosthetics lab at Hospital Albert Schweitzer, in Deschapelles, about two hours northwest of the hospital in Cange. Hanger representatives reached out to Donatien, and she was among the first patients at the company's weekly mobile clinic.

Which is how, on a sunny Saturday in March, Hanger's lead prosthetist in Haiti, John "Jay" Tew, 38, a Baton Rouge native with a soft voice and soulful touch, took measurements of her stump and of her sound arm so that the dimensions of the new arm would be appropriate for her body. Using a thin tape, he measured the circumference of her wrist. He measured the distance from her elbow to the tip of her middle finger. He measured the width of her palm.

The next day, Tew shipped the measurements and a plaster cast of Donatien's stump on Hanger's biweekly flight to the United States. They were routed to a Cajun colleague known for his expertise in building arms.

In Lafayette, John "Tra" Harris, 41, went to work. He put hours into the arm's construction, using Tew's measurements of Donatien's residual limb to create a custom-fitting socket.

Fit and patient acceptance of the limb are the most important considerations, followed by functionality, he said, because if the arm is uncomfortable or unpalatable, the patient may just put it in a corner and never use it.

A single-arm amputation is a particular challenge, he said, because the patient can work around the disability by relying on the sound arm. Double-arm amputees often are more motivated to use prostheses, he said, because without them they are helpless.

"You want (the prosthesis) to be as light and strong as possible," said Harris, cradling the arm as he worked on it.

Harris, a former military policeman who was assigned to the U.S. Army's 82d Airborne Division during Desert Storm, built Donatien's arm on a plaster mold using woven Kevlar, carbon-fiber fabric, and liquid resin to bond the layers. In the world of prostheses, human skin tones are rated zero (the whitest white) to 18 (the blackest black). To match Donatien's chocolate complexion, he tinted the resin with No. 16 dye.

"I love arms," said Harris, a pickup-driving good old boy with a taste for Marlboro Lights. "Arms are challenging. Arms make you think."

The state of the art in high-tech prosthetic arms are $35,000-plus myoelectric prostheses driven by tiny motors controlled by muscle contractions and the body's electrical impulses. But such gadgetry is impractical in Haiti, Harris said, where many areas lack electricity, and batteries are not easily recharged.

Having lost his right thumb in a winch accident in the Army, Harris speaks from experience when he says, "There always is a depression when you lose a body part, because you can't do what you used to do. ... I thought I'd never use my hand again."

But after many operations, his deformed hand is functional and strong.

"Adapt," he said, as he boxed Donatien's arm for shipment to Haiti. "Adapt, and overcome."

From Lafayette, the arm was shipped via UPS next-day air to Bloomington, Minn., arriving hours before Dale Berry, Hanger vice president of clinical operations, was scheduled to leave. Hurriedly, Berry cleared space for the arm in his baggage and rushed to the airport, making the flight with no time to spare.

Meanwhile, Mehta, the HUP surgeon, had returned to work in West Philadelphia. He told friends he felt changed, inspired but also worried by what he saw in Haiti.

"I wonder what it is that we (did there) - how it even makes any bit of difference when there is no follow-up really, no prosthetic care, no therapists to do crutch training," he wrote in a journal that he shared as a blog.

He just happened to be at a World Cafe fundraiser for Haiti in March when he learned through contacts that Donatien would get an arm. Speaking from the stage of the benefit concert, he told the crowd of several hundred people he was overjoyed.

"I did what needed to be done," he said later of the amputation. "I also knew that in a place like Haiti, there was a good chance she would never get an arm ... that she might simply fade to black."

Pressing forward to her appointment with her new arm, Donatien switched vehicles at a transit stop in the provincial town of Mirebalais and took a seat in a "tap-tap" taxi crowded with 14 people, including the driver. The battered Mitsubishi SUV looked like a human sardine can on wheels. "How many people fit in a tap-tap?" goes a Haitian joke. "Two more."

By sheer coincidence, Donatien squeezed in next to Chupet Aurice, whose 6-year-old son, Stanley, was perched on her lap. Crushed by a collapsed wall, the boy's right leg had to be amputated below the knee. He, too, was headed to Hanger's mobile clinic in Cange, at Zanmi Lasante, the hospital where Donatien's surgery was performed.

The rest of the week, Hanger's operation is based at Hospital Albert Schweitzer. The 100-bed hospital on a former banana plantation was founded in 1956 by Dr. William Larimer Mellon Jr., a Pittsburgher whose father founded Gulf Oil. It is the main medical facility for more than 300,000 impoverished Haitians in a central valley that was largely spared by the quake.

Jesus was stenciled in small block letters on the windshield of Donatien's tap-tap. On the back window: La Promesse de Dieu - "the promise of God." The driver had to roll-start the jalopy because its ignition was broken.

Louis Metayer, an official in Haiti's Secretariat of State, is in charge of his country's portfolio on the disabled.

"Even before the disaster," he said, 80 percent of the nation's estimated 80,000 prequake amputees "could not afford even a minimum fee for a prostheses." That meant anyone missing a leg usually spent a lifetime on crutches; a missing arm remained a stump.

Quake victims are the urgent focus now, he said, but any long-term plan for a self-sustaining prosthetics industry in Haiti needs to encompass all of the country's amputees.

Donatien's sweaty ride on unpaved roads eventually wound past Lac Peligre, a vast lake and its massive hydroelectric dam completed in 1971 as a gift to Haiti from the United States.

Donatien was silent for most of the trip - lost in thought about what her new arm would look like, she said later. But the sight of the lake perked her up.

"Those are fisherman," she said, pointing to a cluster of rowboats. Little Stanley leaned forward to have a look.

The first person Donatien ran into after finally arriving at Cange was her daughter Soleikah's godfather, Prosper Desjardins, an oxygen technician at the hospital. The childhood friends, who met at school in Lascahobas, were happy to see each other again.

He took a step back to take in the injury that had destroyed the symmetry of Donatien's body.

"Be strong," he said embracing her. "It is life."

She smiled and hugged him.

On the patio, where the weekly clinic is held, Donatien joined two women, ages 25 and 33, originally from Port-au-Prince. The older one's right arm was amputated above the elbow. The younger one's right leg was amputated below the knee.

After a few minutes, Tew appeared. A Hanger manager on leave for three months from his Baton Rouge practice to run the Haiti operation, he entered carrying a black duffel bag stuffed with tools and Donatien's new arm.

Dressed in tan scrubs, Tew sat shoulder to shoulder with Donatien on the patio's wraparound stone bench. He nonchalantly removed the arm from the bag and laid it on his lap.

For its introduction to Donatien, the brown limb was dressed in a sleeve of white gauze. All eyes turned toward the arm. Suspense filled the air, as when an artwork is unveiled. As Tew peeled back the gauze, Donatien cast a sidelong glance at the arm, averted her eyes, looked back at it, and then glanced briefly at her stump, sizing up how it would fit.

Through an interpreter, Tew reassured her.

"If something is not the right length or doesn't look just right for you, don't worry," he said. "We are going to make it better."

The first attempt to insert Donatien's residual limb into the socket of her prosthesis failed because the soft tissue at the end of her stump bunched up, hindering her ability to push.

Patiently, Tew dusted the stump with baby powder to make it glide more easily and tried again.
"Pull up, then push down," he instructed her, blending English with a dash of French. "Push, Sonia, poussez."

Before trying a third time, Tew took away the arm and used a portable power drill to open a small hole near the hinge that serves as the elbow joint. He threaded a long sleeve of gauze through the hole, then slipped Donatien's residual limb into the open end of the gauze as though guiding a foot into a sock. Thus arranged, he inserted her stump into the prosthesis and used a push-pull motion to tug her limb completely down into the socket.

"Is that you?" he said, wiggling his pinky in the hole to confirm that the stump was properly seated.

Sweat glistened on Tew's forehead as he helped Donatien put on her light, long-sleeve jacket. With only her prosthetic hand showing at the end of the sleeve, she looked balanced and whole again. Together she and Tew took a walk on the hospital grounds so she could try out her new body image.

"Can I hold your hand? Do you have a boyfriend? I don't want to get beat up," Tew, who is married, gently teased.

He showed her how she could use the prosthetic hand to grip her purse, leaving her sound hand free for dexterous tasks like writing, turning pages, or dialing a cell phone.

Even when she learns to master her prostheses, he said, she will probably have less than 20 percent of the function of her natural arm. But she will be able to use the artificial limb to grip or stabilize items and her sound hand for intricate work.

"I'm getting a good vibe of acceptance," Tew said. "She's looking at it. She's touching it. She's comparing the hands. She's not saying, 'It hurts. Get it off.' "

The fit of the arm and of the shoulder-holster-style harness that secures it will require more tweaking. For now, Tew just wants Donatien to get used to wearing it, so he did not connect the thin cable that will control the opening and closing of the hand. That will be for a future appointment. Just start wearing it "an hour in the morning, an hour in the afternoon, and an hour in the evening," he told her.

She left the hospital wearing the arm and found it "easy" to maneuver when she slid into a less-than-typically crowded tap-tap for another bumpy hour's drive back to Lascahobas.

She has kept to the three-hour-a-day regimen, even though Soleikah was initially afraid of the arm. "But little by little, and more or less," Donatien said, the child is coming around.

Beyond preparing her daughter for school, and picking her up at noon, Donatien has little reason to leave the house. Her only recreation is on Sunday mornings when she goes to church.

Through the hospital in Cange, a newly hired physical therapist will teach her to make the most of the arm's functionality.

Unemployed now in a chronically poor and shattered country, she doesn't know where her life will take her.

Her first meeting with her new arm is just the start of a relationship. It will be months before their ultimate compatibility is known. She is impatient to have the cable hooked up so she can make the arm move. But she is grateful to have come this far and is beginning to feel whole again in a land where amputees don't usually get that chance.

"With the help of God, I feel very fortunate," she said. "Other people lost more than I did."