WMS Members Respond to Haiti
Member: Dr. Paul Auerbach
Click here to view Dr. Paul Auerbach's recent article in the Wilderness Medicine Magazine.
Member: Dr. Ashley Bean
Impressions of Haiti
While wilderness medicine is usually not associated with providing care in the middle of a city of 3 million people, my recent trip to Haiti proved to be an exception to this rule. As I packed for the trip, I felt more like I was getting ready for a weeklong camping trip than 8 days of caring for patients. My tent, sleeping bag and pad and water purifier commandeered more luggage space than my scrubs and stethoscope. In addition, I sprayed all my clothes with permethrin and filled my prescription for chloroquine.Once in Haiti, we had limited resources. For this trip, I was fortunate to volunteer with Partners in Development, a group that has worked in Haiti since 1994, and has built a medical clinic. All clinic supplies were donated and hand carried to Haiti. The goal was not to practice ideal medicine; rather, to practice the best medicine possible in an austere environment. The experience least like my regular job was the home visits. For the great majority of the 1 million people living in temporary shelters, "homes" actually consisted of plastic tarps with a dirt floor. We were able to drain a perineal abscess on a young lady who was unable to get out of bed during one tent village visit. In addition, our team provided follow up care for a woman who had undergone orthopedic knee surgery and performed pre-natal visits.
Most of the patients I saw were able to visit the clinic and were there for primary care. The most common complaints were insomnia, headache and epigastric pain; however, my most interesting patient was a woman who had had her face slashed with a machete. There is nothing like doing a complex facial plastics closure with 4-0 nylon. We also saw strikingly high blood pressures, hyperglycemia and congestive heart failure exacerbations. The challenge was to educate patients on the long term consequences of their illnesses while they were understandably more concerned with the short term needs of food, water and shelter. With the existing health care infrastructure badly damaged, some of my patients had been unable to obtain prescription refills; however, the majority of patients had never been under the care of a physician. Before the earthquake there were approximately 3 doctors per 10,000 people, compared to an average 30 per 10,000 in developed countries.
Just like being in the wilderness, we also had to contend with risks to ourselves not encountered in typical everyday practice. Fortunately, the most serious illness experienced by the group was traveler's diarrhea, but the risk of other medical issues from motor vehicle accidents, to dehydration, heat exhaustion and malaria was present.
Overall, I feel fortunate to have participated in such an enriching experience. I not only grew as a physician, but gained confidence in my ability to provide beneficial care in suboptimal circumstances.
Member: Dr. Ramon RiveraI first visited Haiti one and a half years ago as part of an ADRA (Adventist disaster relief agency) project to give medical care to people in city Soleil, one of the poorest neighborhoods of Port Au Prince. What I saw there that time was despair. I returned back approximately two weeks after the earthquake knowing that if it was difficult to live prior to the quake, it would be many times worse after it.
Our group in Puerto Rico had been collecting water, food, clothing, electrical generators, shelter, and medical supplies for a total of 10 containers. The airport was closed, so we had to ship everything to Santo Domingo and then road convoy to Port Au Prince, as the border was open. We got there by night and for security reasons slept beside the airport strip that was guarded by the US Marines and was the place where all rescue teams were.
The second day caught us early and with great difficulty we were able to deliver the containers to its final destination. Initially we were planning to give aid to a hospital, but it had more than enough volunteers so our strategy was changed and decided to work outside at the refugee camps. There were many of them.
People were shocked by the initial movement and even though their houses were spared, they were afraid to go in because of the constant aftershocks. Camps were made of bed sheet over wood poles forming tent like structures where people were cramped with no water or electricity and very poor hygienic conditions. Our group (three physicians and one nurse) targeted a 12,000 people camp near the hospital. First we addressed public health issues; people were defecating everywhere, there were legions of flies; besides, gastroenteritis, dehydration, and infected wounds were taking its toll. It took some time to organize leaders to dig a total of 12-15 latrines around the camp and later provide them with disinfecting materials. It took days for them to dig. After this, bottled water was distributed along with food for two days. Next was to help them with their medical needs. We had to work in the open field because although there was a structurally solid school nearby, people wouldn't go in because they were psychologically affected.
Initially clean wounds and amputations had become infected, so we first cared for the wounds the best we could and gave them antibiotics (we had a good supply of antibiotics). Dehydrated patients were given PO or IVF's according to the needs, using trees as IV stands. Skin problems, respiratory, hypertension, occasional diabetics, and many anxious patients were the order of the day.
We spent four days like this. I give God thanks for the opportunity that He gave us to help our neighbors and to WMS for the opportunity to learn pre-trip planning, how to stay healthy in hostile environments, to give field health care, and how to continue healthy when back home.
Member: Toby Savage, PA-C, FAWM
I was in Haiti 2 weeks after the event. The airport was far from being "open", so the team I was with flew into the DR, then took a UN flight to Port au Prince. We were assigned to operate a clinic in the outlying area of Carrefour. We were in the middle of a tent village of many thousands of homeless people, so many of whom required medical care.
Out "clinic" was set up in the remnants of the church, and each day our "waiting room" was a frightening throng of hundreds. We had a security detail to keep the crowd in some semblance of order, but managing to triage properly was very challenging.
The range of injuries we were seeing was extremely varied. Many devastating soft tissue injuries, fractures, and as it was only 2 weeks out, we were just starting to see illnesses related to lack of clean water and shelter. I did not see tetanus, but it was starting to appear in some other areas. Soft tissue infections were becoming very common. Our clinic was well stocked with antibiotics, and dressing supplies, but we were not equipped for major debridements. But when faced with no alternatives we simply did what we could with what we had.
A referral system for further care for many of these patients simply was not in place, so we would see them over and over for continuing wound care. It was rewarding, but very frustrating all at once. We were a team of 5. Two physicians, myself (a PA ) and two nurses. We saw 200 patients each day. It was exhausting, we all were suffering from our own illnesses related to heat, dehydration, and GI issues... this made a difficult situation more so. One of the trips we made into an outlying area which was reduced to rubble, still had the remains of victims in the streets. If one looked you would see arms sticking out thru the concrete debris. It was truly heartbreaking. The enormity of the situation in Haiti is not to be appreciated unless you have seen it with your own eyes...and even now..it doesn't seem real.
Member: Dr. Craig Hatton
I am an orthopedic surgeon in Layton, Utah. I have been a WMS member since 2004. I retired from the Air Force in 1996 and went into private practice in San Marcos, Texas for 12 years. I am now "semi-retired" with Intermountain Health Care.
A group of Physicians and Dentists travel to Haiti and the Dominican Republic several times each year to visit remote villages under the support of a 501c3 charity called IASK. A trip was planned for Feb6-14 and was proceeding along with the usual planning, fund-raising, etc. When the earthquake struck on Jan 12,2010, the trip as originally planned was in jeopardy. A quick restructuring which changed destinations, made the group smaller and added several emergency trained nurses and me was necessary. Our new goal was to travel to an area devastated by the quake about 40 miles west of Port-au-Prince and use a Mormon church meeting house as our base of operations. The town of Leogane has a large nursing school and a filariasis research institute run by Notre Dame. A group of medical personnel had traveled there one week after the quake to assess the damage and needs. The trip was lead by Marc-Aurel Martial, a Haitian born nurse, who has lead several primary care missions into Haiti. His family lives in P-a-P, their house was damaged but still standing. Our team was reduced from 40 to 25 and included 4 PCPs, 1 Ortho Surg, 2 Dentists, 6 Nurses, 4 EMT/Med Techs, 2 Dent Techs, 3 Pharm, 3 support pers. We carried all of our equipment including generators, air compressors, and my baggage was 250 lbs!
The first problem was the closure of P-a-P air port. We changed at the last minute to Santo Domingo and with the help of LDS church in the DR, were able to arrange bus transport to Haiti. It was a 10 hour bus ride with many stops at check points but more important, it took away 2 work days in country. The bus ride took us through P-a-P where we saw the devastation then along the southern peninsula to Leogane. Setup went into the night with 300 people at the gate well before dawn. Limited electricity from a generator, water from a well and filtered heavily , food that we brought supplemented by the 150 homeless church members living in the compound. We let 150 in the gate then began triage. I saw many open wounds, casts in disrepair, amputations and untreated fractures. The injuries were now 3 weeks out and with no surgical capability, treatment was primitive. The PCP's saw and treated lots of basic medical conditions, HTN, pregnancy, abdominal pain, stress, headaches, all of which originated from "the Event"!!! As the morning progressed, my needs for more support- especially X-ray became pressing. A vehicle and driver allowed me to search for other medical facilities, the hospital was severely damaged and deemed unsafe, MSF had a treatment facility but no Xray, a Cuban military hospital was starting to provide rehab services but was a closed unit, a Japanese military was located at the nursing school and had Xray!! The big bonus was to find the American hospital team working out of the nursing school, personnel coordinated by World Wide Village charity, with support from Notre Dame. On my chance arrival, I found a urologist, 2 plastic surgeons, a general surgeon, 2 anesthesiologists, total disorganization or supplies minimal surgical drugs and another orthopod who, just like me had wandered in looking for a place to help. We spent the next several days seeing all the patients referred in or returning, and organizing the supply mess.
OR facilities were primitive to say the least. A room with open window, no water or electricity. one small sterilizer able to do a small pan of individual instruments in 1 hour! Heat and poor air flow made any attempt at sterile technique futile. Anesthetics included Versed and Ketamine. No Oxygen was available. Many of the dressing supplies were expired, but clean. We performed many amputations or revisions, treated some fractures- external
fixation or pinnings, changed lots of casts and did hundreds of dressing changes. Full thickness skin graft was a common procedure. The support of the Japanese Xray team was essential. Each evening I would return to the church and see clinic for several hours that had been saved by the PCP's. No one complained about to long of a wait. Each night my group would hold a 1 hour meeting to discuss the day and suggest possible process improvements. This made the triage and clinic function better and more efficient. I continually expanded my outreach to allow more support for the team. One of the vital functions was to find other treatment facilities and note their capabilities in order to link the care throughout the region. Examples are the need for inpatient care, access to the P-aP hospitals, and transfer to the Mercy USN hospital ship. The UN was still struggling to keep up at almost 4 weeks after the quake, and volunteer charity groups were arriving daily looking to help.
One interesting story. At the hospital, one of our teams nurses made the acquaintance or a Haitian nurse named Regan. He had recently graduated from the nursing school. With some support from the hospital team, and Nurse Tammy, he started to do outreach trips into the surrounding community. Traveling 20-30 miles to villages that had seen no outsiders. He did amazing work and should be praised as a national hero. I wish his story could be told- after loss of family members in the disaster he responded to the overwhelming horror, and created a vital service to his country. I will attempt to attach a news story about him and a link to his blog.
We had one tragedy- one of the dentists was stuck by a needle from an HIV positive patient. With the arrival of the rainy season, Dengue fever is on the rise, and we saw many malaria cases. The lectures of the WMS on tropical diseases were beneficial in reviving the ancient medical school knowledge of Filariasis, Dengue, malaria, etc.
Lessons learned: The good intentions of individuals of individuals requires adequate support which is difficult to find, especially after a disaster. Simple is better. The use of castile enema soap as a cheap wound cleanser is superior to complex and expensive surgical antibiotic washouts. A healed fracture in malunion can be functional in this environment, osteomyelitis which drains occasionally can allow a person to support his family, whereas an amputation can make a man or woman an outcast. Lots of further rehabilitation and reconstructive work remains to be done, but only with the caveat of first do no harm.
Member: Brenda Tiernan, RN
I arrived in Port au Prince in May, several months after the earthquake. Although much time had gone by the devastation was still remarkable. Part of the University Hospital had relocated from tents to remaining structures not destroyed by the quake. The ED was now inside, powered by generators or sometimes not at all. Headlamps were an absolute necessity.
We still had no running water in the ED. Medications were from numerous sources and consist of sample packs, loose pills in large jars, individual prescription bottles left by others, and pharmaceutical donations from many different countries labeled in Spanish, French, Creole,and Korean among others.Supplies were still limited and we fashioned many splints, slings, and dressings. We resorted to reusing items for lack of any others. Oxygen supplies were very low. Much trauma is seen from falling structures and debris as people attempt to make a dent in clearing away the rubble. Medications go quickly and you hope for enough sedation,
narcotics and antibiotics to keep your patients alive and as comfortable as possible. Lab turnaround times can be hours or not at all. Xray runs out of film. Blood bank rarely has blood. Diagnostics are based on hands on assessments.
Sadly, there is much violence in the tent cities...shootings, stabbings, wounds from machetes, thrown rocks and gang rapes, victims as young as eight. Police protection is very limited. And gruesome burn victims are seen. Candles ignite the fuel rich tent fabrics, laden with grease and cooking oil residues and whole families are charred to death. It was very tragic and distressing. Though the number of patients seen daily has decreased dramatically, there is still a constant flow of people waiting to be seen and sometimes we had to
cut up boxes and use the cardboard as mats for beds on the floor. We saw cases of Cerebral Malaria, Tetanus, Typhoid, TB and occasional Dengue and Diptheria. We watched with great sadness as many of our patients died, but were also rewarded with those we were able to save.
This catastrophic event will take years to recover from in a country already burdened with a healthcare system way below our standards and a population with a high incidence of HIV. But despite all they are dealt with, the Haitian people have not lost hope. They are accepting; they move on. They come to us for help and are grateful for what we can and cannot do. I became very invested in my Haitian patients and friends in my short two week rotation. It was very hard and exhausting work but very rewarding and I am sad to leave.
Member: Scott E. McIntosh, MD, MPH
We arrived in Port au Prince on March 30, seven weeks after the earthquake. Teams before us had been treating acute injuries as a direct result of the quake - amputations, wounds, general trauma resulting from the collapsing structures. While most of these acute injuries had been treated, the acute phase of the disaster was far from over. The quake ripped through the medical system as well as the soul of the country, and the Haitians and
international medical providers were just beginning to realize that the task of rebuilding will be harder than they imagined.
The medical system that was in place before the earthquake was typical of third world countries. Advanced procedures were limited and when they existed were privatized and high priced. Vaccinations were sparse and chronic medical and infectious conditions abounded. At the same time as the earthquake toppled buildings, it toppled this already bare bones medical system.
Our International Medical Corps (IMC) team had established an Emergency Department on the grounds of Hospital Universite d’Etat d’Haiti (HUEH). IMC had been staffing this ED with emergency and family practice trained physicians and nurses 24 hours a day since just after the earthquake. We, like the rest of the hospital, were working out of tents. Engineers had deemed most of the buildings of HUEH safe for occupation, but the people were still hesitant to move inside structures which had attacked them so viciously seven weeks prior. This, accompanied with the fact that hundreds of patients still lay in cots under tents, proved a logistical challenge to practice even the most basic elements of medicine. We still had no monitors, laboratory operations were still intermittent, and surgical intervention was limited. Medical relief workers continued to arrive and treat patients day and night, but understandably had little time and reserve to mount extra logistical and organizational skills to convert the tent hospital to a more functional unit.
The help and skill of the medical relief workers was generally welcome as the limited staff of HUEH seemed exhausted. The number of local doctors and medical staff was sparse, having lost many lives to the earthquake. For those who survived, motivation to return to work was lacking as many of the survivors had lost their homes and families. Funding for their work was always in doubt. When we tried to admit two women in active labor at 2am to the Labor and Delivery unit, we were kindly told that they could not accept any patients at this point in the morning. After the sun rose later that morning they then told us that our woman with eclampsia could not be admitted because the OB doctors were on strike. As unacceptable as this may seem, it is hard to criticize a group of professionals who are overworked, under (or not) paid, and largely tending to wounds other than those of the hospital patients.
Even seven weeks after the quake with billions of relief dollars having poured into Haiti, we were surprised by the lack of equipment and adequate medical care that was available. Trying to treat even the simplest traumatic cases, for example a pneumothorax, was complicated by the fact that no suction devices were present (or at least could not be located) for a tube thoracostomy. We were still practicing medicine at the basics – operating solely by clinical skills most of the time and creatively improvising for much of our medical care. Blood was still very scarce. We treated a woman with sickle cell anemia whose hemoglobin had dropped to 2.6. Although the blood bank at the HUEH was now operational, they could not locate any blood that matched our patient. After polling our medical staff who was working that night, we finally found a physician who was O negative. She rolled up her sleeve and donated a unit of whole blood to the patient, hopefully extending her life until her relatives could travel to Port au Prince and donate
blood to her. The Haitian medical system, which was scraping by to begin with, had suffered a devastating hit. Normalcy will be a long time coming.
We were providing the first organized emergency medical care that Haiti had seen. The country was struggling to adjust to their new reality. Accidents relating to the cleanup of fallen buildings as well as additional trauma from falling buildings were common occurrences. The tent cities which house thousands of people in close proximity are a hotbed of sanitation problems and diseases which spring from poor public health. Furthermore, this type of living situation undeniably creates a tension that can be felt throughout Port au Prince, and unfortunately guns and machetes are drawn quickly when disputes flare.
It was inspiring to see the many forms of international relief efforts that were mounted. Global DIRT (Disaster Immediate Response Team) helped immensely with transfers between HUEH and other facilities. Partners in Health operated the ICU during the nighttime and performed a number of needed surgical procedures. The state of medical care would likely continue to be in a disaster status if the international community had not mounted such an enormous effort. In any disaster situation, medical care must be eventually and gradually transitioned back to the local people. The Haitians are an incredibly strong group of people, and this will hopefully occur in due time. However, this transition seems wildly distant at this point. They still need help.
