Planning for Haiti: week 1

Exactly 1 week ago, I agreed to go to Haiti on a humanitarian mission.  Given a little experience in Vietnam and Afghanistan, I thought I had the skills to help. The difference was that in those missions, a preexisting infrastructure of care and healthcare delivery had already been established.  So the challenge was to build the medical team that could make a difference in Haiti, just 3 weeks after the earthquake.

The response was immediate and complete.  Of course Minh Nguyen, MD, was on board. He started the whole effort in the first place.  His interest started when he rode his bicycle across the country to raise money for charity.  He ran into Project Help Haiti and knew it was a good cause with good infrastructure. As a chief resident at the Ohio State University, he is at the pinnacle of his knowledge of Orthopedics.  Working on a daily basis in a level 1-trauma center, there is little he hasn’t seen or hasn’t done.

David Kasserman MD.  General Surgeon volunteered after only 6 hours of contemplation.  After training in New York City, he has amassed a ton of experience with both rural and urban general surgical emergencies.  Well regarded in at least 4 different hospitals., he’ll bring expertise to abdominal trauma and injuries.

Amy Bush RN serves currently as the VP of Operations at Dublin Methodist Hospital.  A former critical care nurse with experience in mission work in the Caribbean and well as travel experience through China, travel into inhospitable environments are not foreign to her.   In addition, she has an MBA!

Regina Chen, RN is probably one of our best PeriOperative nurses.  She knows the ins and outs of getting patients ready for surgery and getting them through surgery. With little equipment in Haiti, she’ll be able to put her resourcefulness to the test.

And finally, Ed Chen, MD.  Chief of Anesthesia at Dublin Methodist Hospital.  I’ve known Ed since he was a resident at Ohio State University.  Even then he was an agile clinician who found physiology more interesting than the mundane world of surgery.  He got even better as he got specialized training at the Cleveland Clinic.  With a recent trip from Africa under his belt, he’ll be our best asset on the trip.

Logistical planning into a disaster zone is difficult.  There are no commercial flights to Haiti currently.  Landing slots are tightly controlled.  We were able to get clearance for our mission dates of February 13 to 20 through Project CARE.  With a lot of pleading through Facebook and Twitter we were able to acquire a jet.  But with every victory, there is a little loss, and we found out the pilots who have been shuttling teams nonstop have reached their monthly quota of flight time.  We may have a jet, but we don’t have a pilot.  Our search continues.

In addition, the xray machine, which was marginally operational, finally broke.  Again with more pleading and begging on Facebook and Twitter, we found a mini-C arm. With a weight of almost 900 lbs, we face the challenge of shipping it down to Haiti.

Interest from the orthopedic community remains high despite negative reports from some of the earlier missions.  Ruth Thomas MD from Little Rock, head of the Humanitarian Committee of the American Orthopedic Foot and Ankle Society is beginning to plan her own mission 3 weeks following ours.  Rob Veith, MD, my teammate from a Vietnam mission is flying to the Dominican Republican and plans to get to Haiti overland!  Mark Slovenkai, MD, another surgeon with Vietnam background is considering a mission shortly. Joao De Carvalho Neto, MD

But the greatest interest comes from our friends, families, and neighbors.  I get daily volunteers willing to join.  Regardless of skills, there is a great sense of desire to come into a dangerous region and just help.  Pretty inspiring.

We’ll be evaluating all of our donated medical supplies this week.  Hopefully finalize flight plans.  With continued contact with teams 1,2, and now 3 (leaving today), we’ll try to define our medical goals in the coming days. We’ll keep you up to date through Twitter, Facebook, and this blog. I anticipate the chaos to only get worse with time.

Immunizations now up to date.

My thoughts after a week revolves around the many offers to help.  Volunteerism seems to be a root element of our culture.  It is yet another aspect of our community that we can be proud of.

Haiti street scene before earthquake

At 4:53:09 pm on January 12, 2010, 15 miles southwest of the capital city of Port-au-Prince, Haiti, an earthquake measuring 7.0 on the Richter scale struck. In the ensuing days, its estimated that 200,000 people lost their lives.  As phone camcorders documented the Asian tsunami disaster, Twitter and blog feeds recorded the devastation in real time.  For many of us on Twitter at the time, we’ll recall the flurry of activity on our Tweetdecks.

As an active orthopedic practice with some experience in humanitarian missions, the question of how to help came up rapidly.

Several influential teams responded rapidly. Here is an email from Dr. Dean Lorich who participated in a rapid response team within the first week:

I believe we went in with a reasonably comprehensive service we wanted to provide acute trauma care in an orthopedic disaster.  Our plan was to be at a hospital where we could utilize our abilities as trauma surgeons treat the acute injuries involved in an orthopaedic disaster.  We expected many amputations however came with a philosophy that would reasonably start limb salvage in what we thought was a salvageable limb.

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

With these obstacles in mind, Minh Nguyen MD, a chief resident at the Ohio State University recalled an established organization he interacted with while riding his bicycle across America fund raising for Partners in Health.  This group, Project Help Haiti, ran an established orphanage in Pierre Payen.  This orphanage and hospital sits about 60 miles north of Port-au-Prince.

http://www.project-help-haiti.blogspot.com/

Because they had an intact infrastructure, they have been able to maintain a functional hospital through this disaster.  With a goal of serving the disaster but more important to keep a functional mission in the months/years to come, they have been sending medical missions rapidly.

With donated private jets and clearance from the 82nd Airborne, 7 teams have been organized.  Team 1 is just returning while team 2 has landed.  Here in Columbus, we are assembling team 5 for a departure of February 13.  Planning a team of 2 orthopedic surgeons, 1 general surgeon, 1 anesthesia, and 2 nurses, our goals will be to get on the ground and help in anyway possible.

This team will land almost exactly 1 month after the earthquake strike.  The challenges will be different from the acute devastation of the first few weeks.

Unlike the usual challenges of orthopedic surgery to return function, our goals here will focus on stabilizing bodily function and averting infection.  And in the end, hopeful save a life.

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