Reflections on Haiti

I guess we were lucky. I was at a private hospital in a region called Sacre-Coeur near downtown called CDTI. There were a lot of people with wound infections of course, but still a lot of broken bones and quite a few dehydrated adults and children. I think that typhoid is coming next, I saw my first patient with typhoid two days before I left...there still is a great need for some non-surgical items such as blankets, tents, cots for the patients, pens, notepads for documentation. There is also a need for sterile surgical supplies, ortho supplies... There are a lot of external fixations being performed. Casting material is still needed... The thing is that not all hospitals have the same needs. One HUGE problem is that if the supplies are just sent with no specific destination or without someone accompanying them -- even if the destination is specified, they might stay on the tarmac for days unclaimed. If you want to send to specific hospital, it has to be arranged beforehand. It is still a huge source of frustration.

The field hospital is run by a variety of physicians with expertise in emergency preparedness and disaster organization.  It has amassed volunteers from a variety of organizations with nearly all countries represented...Today, I participated in wound care for dozens of patients on a surgical service that accounts for the majority of post-earthquake victims. Each has predominantly orthopedic wounds and injuries resulted from the earthquake as most patients throughout the country with more severe injuries to chest, abdomen or head have died... The comraderie and colleagality across discplines, nationalities, race/ethnicity is remarkable and unparalled in any experience that I have had. The reasons -- the Haitian people!  Volunteers work tirelessly while sleeping in tents, eating whatever food they have brought with them taking showers with buckets of cold water... Despite these minor inconveniences (being facetious), this has been a trasnformative experience. I would like to highlight three major concerns going forward:  One, the effort of the international commmunity has unearthed a desparate and deep need for care, not only acute trauma care, but for chronic care. In the my first 20 minutes in Haiti, at a Christian Mission, I saw people suspected of acute cholecystitis, prostate hypertophy and inflammatory breast cancer. Not a single one was related to trauma. That clinic saw 500 patients that day. Two, this is only the beginning. The resultant injuries from trauma and surgeries to repair them now have to heal and functionaltiy restored.  The need now and going forward is not so much for doctors to perform miracles, but for physical therapists, nurses and allied health professionals to help the Haitian people RECOVER from these injuries! We need your help.  Last, the notion that now is not the time to volunteer, or its too hard to get to Haiti or you may have nothing to contribute is a fallacy.  I arrived here with little more than the idea that I wanted to make a difference. Nothing more.  I used every connection I had, ever resource at my disposal, and tapped networks to get here with $30,000 in supplies!  You can do it, too!

David Helfet put a team together which included:
2 orthopaedic trauma surgeons
3 orthopaedic trauma fellows
2 highly skilled anesthiologists
1 general surgery trauma surgeon
2 synthes reps who were also scrub techs
1 trauma nurse practioner to do triage
2 OR nurses

Our equipment including a huge amount of anesth medications and equipment, ability to construct 150 ex fix both small and large, OR equipment including scalpels etc, OR soft goods, splint material, OR prep material.

We also had a plan of physician and equipment replacemnt that was dynamic where w/i 24hrs we could bring in what was necessary on the Synthes private jet.

We thought the plan was a good one.

We were incredibly naïve.

Disaster management on the ground was nonexistent. The difficulties in getting in despite the intelligence we had from people on the ground and david helfet's high political connections with Partner's in Health as well as the Clintons only portended the difficulties we would have once we arrived.

We started out friday morning, got a slot to get in friday that was eventually cancelled when we were on the runway to be rescheduled the next day. We diverted to the DR and planned on arriving in P OP saturday.

Once on the ground the hospital we had intelligence that was up and running with 2 OR's General Hospital was included severely in the earthquake and not capable of running functioning OR's as there was no running water and only a limited electrical supply on generator.

We quickly took our second option
Community Hospital of Haiti . We found approx 750 pt in the hospital upon our initial eval, the hospital had running water, electricity and 2 functional OR's
Our naivette did not expect that the 2 anesth machines would not work, there would be 1 cautery for the hospital, autoclave that fit instruments the size of a cigar box, no sterile saline, no functioning fluoro and no local staff only a ragtag group of voluntary health providers who like us had made it there on there own.

To summarize we had no clue the medical infrastructure of the country was so poor.

As we got up and running in the OR and organized the patients for surgery we communicated our new needs back to Synthes and more supplies were loaded for a second trip - these included battery operated pulse lavage, a huge supply of saline, soft goods in the OR. This plane landed as planned sunday pm, equipment was loaded on a truck and subsequent hijacked between the airport and the hospital.

At the hospital we had zero security despite promises form NYPD and NYFD to provide that to us.

Our philosophy was to work like this was a marathon run the OR's around the clock with the idea that we would have a defined extraction time of 11pm tues. The plane that extracted us would come in with a new medical staff compliment to replace us. Equipment included urgent things to maximize issues that were nonexistent in the hospital that would enable us to provide better and more efficient care:

2 portable anesth machines
2electrocautery
2 portable monitors for the pacu
2autoclaves
Replacement exfix
Things that didn't arive with the previous flight

That planes slot was cancelled by the military at 6am tues.
We also previously had seen daylight in the remaining patients monday night haviving completed approx 100 surgeries. However on tues morning we found a huge # of new patients. The hospital was forced to undergo lockdown closing its gates to the outside and outside crowd becoming angry.

We also noted tues morning that many of the patients we were operating on were becoming septic.
We finished operating at noon tues, the last surgery our group assisting an obstetrician on a caesarian and resuscitating a baby that was not breathing.

We decided as a group the situation for us at the hospital was untenable supplies were running out, team was exhauted, safety a huge concern, and no extraction plan with resupply. We decided to make our way to airport thru the help of a hospital benefactor. Jamaican soldiers with M-16 were necessary to escort us out with our luggage as the crowd outside saw us abandoning the hospital.

We made it to airport on back of a pickup track, got onto the tarmac, hailed a commercial plane that carried cargo to montreal and had private jet pick us up there.

The issues we were unprepared for and witnessed were

1. The amount of human devastation
2. The complete lack of a medical infrastructure in the country
3. The lack of support of the haitian medical community
4. The complete lack of any organization on the ground. Noone was in charge, we had the first functional up and running hospital in the P OP area yet noone and I me NOONE came to the hospital to assess what we were doing, what we were capable of doing and what we would need, to be more efficient. The fact that the military could not or would not protect the resupply equipment on sunday or let the tues flight come in says it all.
5. Lack of any security at all at the hospital

I would take away that disasters like this need organization on a much higher level than we had with the clear involvement and approval of the military from the beginning.

Currently there is Noone obviously running the show and care is in chaotic at best. MD's are coming in country with no plan of what the are going to do. Surgeons that expect to just show up and operate are delusional as to what there role would be as without a complement of support staff and supplies they would be of limited or no value.

I hope this helps. We all felt as though we abandoned these patients and that country and feel terrible. Our role now being back in NY is to expose the inadequacies of the system to the media in the hopes of effecting a change in this system immediatly. We feel that the only way to really help now is an urgent programtic change and organization in the support of the medical staff on the ground and what is critically needed to expeditiosly bring in.

Cherrios on the tarmac are not getting it done on these patients which clearly would be savable if good care could urgently be provided.

Please share this email with everyone and anyone you find might help.

Good luck
Dean

Dean G. Lorich, M.D.
Associate Director
Orthopaedic Trauma Service

There were five aftershocks yesterday and there is the possibility of another major earthquake. Lots of people are leaving, and the French government has instructed all of its citizens to leave. There are 1,000 flights waiting to land, with doctors and medical staff trying to get in and supplies to be delivered. Those who are getting in have come with the military or gone through the Dominican Republic. It’s very unsettling and unstable. Many of those who were rescued and operated on are dying from septic shock because of the conditions. There’s not a venue for providing optimal care.

I am also helping with the medical relief at one of the private hospitals that opened its doors to the community since the quake. It has been very busy… I came across a young lady with a very severe congenital heart condition who will likely die in the next couple of years, if not sooner, if she doesn’t get any surgical intervention… I am desperate to help her. She is a lovely young lady…

that another more violent earthquake is likely to occur at anytime. I am very scared. It seems that everyone and anyone who has the means are fleeing the country, whether it’s to the Dominican Republic or elsewhere. We were going to leave to Petite Riviere de Nippe, our hometown, but unfortunately it seems that it was completely destroyed by the earthquake as well… I am very afraid here.”

It leaves one a little paralyzed… It’s difficult to dispense adequate care in the exsisting conditions… Among the buildings leveled by the earthquake were Quisqueya University (a private university), the State University Hospital of Haiti, and the medical school.

I lost an aunt, a 28-year-old cousin, and my cousin’s son… I’ve become an insomniac since the earthquake happened. I feel so sick and helpless watching the 24/7 news coverage and seeing the devastation that occurred in the entire capital. I was really struck seeing the Palais National in ruins. After not having been back in 24 years, I feel a strong urge to return and be part of a medical relief effort.

The devastation, destruction, death and suffering are overwhelming and seem to me beyond what common mortals or all the powers of the world combined will be able to handle or manage in months or years to come… My Mom, sisters and brother, as well as the other 24 to 26 other relatives, seem to be weathering their ordeal relatively well...Trying to evacuate...but the fate of the 9 to 10 million poor is quite uncertain. Keep them in your prayers.

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