Haitian Earthquake Survivors At Risk: Rhabdomyolysis and Compartment Syndrome

By Barbara Lock, MD
January 22, 2010

The plastic surgeon was intermittently sighing, as she watched the endless images of bodies lining roads, extremities dusty, swollen, non-functioning, as they flashed on the television monitor. Haiti, at the mercy of the heavens and western civilization, had been crushed.

"Ahh-mmmm," she sighed, shaking her head again. "I wasn't going to go," she said in her thick french-creole accent. "I told them I couldn't go for a few weeks, until after the reconstruction had started, but I can't sleep. I haven't slept in three days, people keep calling me."

She shuffled a little, standing in place, as if she couldn't figure out where to put a new burden.

"They don't have enough surgeons, and no one knows about compartment syndrome. That 11 year-old girl who was on the news, pulled out from under the buildings, everybody smiling, she died. She looked so good. No one knew to do a fasciotomy. They just need someone to teach them, teach the medical responders."

I nodded my head, but then I pictured thousands of Haitians earthquake survivors laying in rows outside of makeshift medical tents, their arms or legs filleted open, aid workers wringing their hands for the news camera saying 'Now what are we supposed to do?' I shook off the image.

Compartment syndrome occurs when a crushed or otherwise injured body part, usually an extremity, suffers deep swelling, swelling that is trapped between planes of a strong unyielding type of body tissue called fascia. This swelling and injury, frequently invisible to examiners, can cause a significant pressure build up in the body compartment defined by the fascia. If the pressure is not relieved, it will cut off the blood supply that passes through the compartment, causing tissue death.

Patients with compartment syndrome usually describe a deep pain out of proportion to the observable injuries, a pins-and-needles sensation, and sometimes have a reduced pulse. Paralysis of the limb is a late finding.

Compartment syndrome is generally detected through the pressure measurement of deep compartments of crushed or otherwise injured arms or legs using a Stryker intra-compartment pressure monitor. It involves sticking a really big needle deep into the injured arm or leg.

To treat compartment syndrome, a surgeon or someone trained and skilled in the procedure (DO NOT TRY THIS AT HOME EVEN IN HAITI) slices through extremity to the affected compartment, thereby releasing the facia's compressive action on the deeper tissues.

Acute compartment syndrome can be fatal if untreated. So I thought, listening to the plastic surgeon: aren't most victims related to the 2010 Haiti earthquake who did not get immediate care at a fully functioning hospital already died by now? Is it reasonable and possible to screening all earthquake victims for compartment syndrome when there are not enough personel and medical supplies to even dress wounds? You can't just slice open people randomly when there is no infrastructure for aftercare; they'll die from their wounds instead, right?

But compartment syndrome is just one of many medical catastrophes that are in store for victims of crush injury. The more common but also evil twin malady to compartment syndrome is rhabdomyolysis. Rhabdomyolysis occurs when crushed or otherwise injured muscle breaks down, sending little muscle molecules called myoglobin into the bloodstream. Too much myoglobin in the bloodstream can gum up the works, so to speak, and make the kidneys stop working properly. Weight lifters or other athletes will sometimes get rhabdo after an excessive work-out.

Rhabdomyolysis is generally detected through blood or urine tests, and is treated with a lot of intravenous hydration. A couple of liters of water from the relief supplies per day will not be sufficient to prevent kidney failure in earthquake surviors with rhabdomyolysis.

I admired my colleague for going to Haiti to help with medical relief efforts. I watched her looking at the television, a great mantle of sadness and impotence settled on her. She was planning to leave the next day, to hop a ride to Haiti through connections she'd made with the Israeli army. She would bring a small backpack, some medical supplies, and some medical books, she said.

I hope she has made a difference. I hope it has been enough.

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