Letter from the Chair
Stuart B. Weiss, MD, FACEP
This issue of the Disaster Medicine Section newsletter is devoted to the stories of our emergency medicine colleagues who risked their lives and graciously donated their time to help our Haitian neighbors in the aftermath of what may be the worst natural tragedy of the past 100 years. You will read about their trials and tribulations, their triumphs and their frustrations, feelings that always accompany a large humanitarian relief effort. Above all else, these stories point out the important leadership role that emergency physicians play in disaster relief.
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Haiti Visit and Update from the ACEP Ambassador to Haiti
Christopher Buresh, MD, FAAP, FAAEM
ACEP Ambassador to Haiti
We were working underneath trees and shrubs, doing our best to stay out of the blazing sun. Our patients included a child with meningitis who had been in the throes of febrile seizures for hours, a newborn going into renal failure from posterior urethral valves, an old woman who was too wracked with pneumonia to walk, children incapacitated from malaria and malnutrition, and people permanently maimed from untreated injuries. That was our experience in Haiti exactly one week before the earthquake.
Before Haiti had its brief moment in the media spotlight, each day held small scale disasters for the people of this island nation. While many people live in the cities that have recently made the news, the majority of the population lives a rural existence. Many are subsistence farmers who walk for miles each way to get their crops to market. The healthcare infrastructure consisted of about 2000 physicians for the country of over 9 million people. These physicians lived in the cities and operated mostly out of small private clinics during business hours. The few hospitals scattered around the country are a mix of governmental institutions, private facilities, and charitable operations, but are virtually unreachable for huge swaths of the population. One mother we met departed from her home in a panic when her meningitic infant had her first febrile seizure. She made it to our clinic 16 hours later, but was too late by a long shot. While we all rail against the lack of access to care here in the United States, while we work collectively to shape the future of our specialty and ensure its proper place in the pantheon of medical specialties, it is instructive to see what a world is like where there is no 24-hour emergency care.
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The first patient treated by the team with the ACEP Ambassador to Haiti was
a 1-year-old with one-fourth skull exposed. |
We had just returned home from a week in Haiti where we’ve been working to set up a system of primary care in a few villages by training, augmenting, and utilizing the skills of village health care workers. I had just gotten home from a shift and was about to start unpacking my bags when I got a text page about the earthquake from a friend. I became pretty obsessed with getting as much information as I could and trying to figure out how best to respond.
There were two competing impulses at play. I know that well-intentioned people who aren't trained in disaster response can get in the way and absorb resources that can be better put to use. These folks run the risk of being medical adventurers and disaster tourists, and I didn't want to be one of those people. On the other hand, we'd been working down there for a long time, we know the area, and we know the people. We had a great team put together, many of whom had just been on the ground there 3 days before. We’d been asked to come by 2 different local organizations, had 3 different deployment plans, and we had a lot of local support. In the end, we judged that we'd be able to help more than hinder.
Immediately following the quake there was a pretty brisk response in Port au Prince, but there was nothing happening in Leogane, the city in which we normally work. It was nearly 3 days before any media made it the 20 miles west to Leogane and another 2 to 3 days before any medical teams arrived. The day before we got there, disaster response teams from Japan and Doctors Without Borders had made it to the region. The team that we brought was composed of 3 emergency medicine doctors, a pediatrician who’d been coming to Leogane for 14 years, 3 paramedics that had military experience, an emergency room pharmacist, and 2 people who were familiar with the area.
We weren't really sure what to expect. We brought all of the food that we needed, brought tents, and water purifiers. Since we were at the end of the dry season, we discussed water rationing before we hit the ground. The first 2 locations where we'd hoped to set up in Leogane were full of tent cities where displaced people were living, so we went instead to the nursing school where we knew the Dean. She and the nursing students had been treating patients almost without stop for the last 6 days. Their first patients arrived within minutes of the earthquake. They’d been out of gauze, sutures, antibiotics, and gloves for several days when we arrived.
We set up our tents and got to work putting the clinic up. We constructed the clinic by stringing some webbing between 2 wings of the nursing school and putting up tarps over the courtyard. Within 2 hours of getting out of the landcruiser, we were seeing patients. The first patient we treated was a 2-year-old girl who had a quarter of her scalp peeled back in the earthquake. She’d been walking around for 6 days with her skull exposed, but blessedly intact. We did all of our work outside on desks that the students had been using the week before. There were a lot of badly injured people and we didn't have much to offer them. For the first 3 to 4 days, the only analgesics that we had for people’s open fractures were Tylenol.
On the afternoon of our second day, a Blackhawk helicopter landed with a team from Minnesota and Wisconsin that included an orthopedic surgeon and critical care PA. In the following days, other teams arrived bringing more orthopedists, general surgeons, anesthesiologists, primary care physicians, and nurses. We were able to barter with other non-governmental organizations in the area for some supplies that we needed, particularly ketamine. Our surgical teams started doing amputations in the classrooms without any patient monitors or supplemental oxygen. After the ketamine wore off, however, all we had was Tylenol. Postoperatively patients were kept in tents next to our own so that we could deliver some postoperative care.
The Haitians were incredibly tough. We didn’t have wheelchairs or stretchers, so we often had to carry people around in our arms when they had a broken pelvis or broken legs. It’s just not possible to stabilize the fracture when you’re supporting someone in your arms, so it’s incredibly painful. But patients never complained. In fact, when you would set them down they would look right at you, sometimes with a tear running silently down their cheek, and say "Mesi anpil." Thanks a lot.
More supplies and expertise arrived over the following days. We began to link up with teams from Japan, Canada, Cuba, Switzerland, Austria, and others. We worked through the United Nations to share resources in terms of medicines and expertise. We’d trade IV tubing for plaster, crystalloid for ketamine. Shipments of anesthetics and narcotics began to come in. A week later we began to get crutches. Every day we’d rearrange the tarps that had become our clinic to repair the damage the wind had wrought and to try to keep our patients cool. Twice the thermometer in the shaded "pharmacy" climbed above 105 F. The duct tape melted.
In the subsequent weeks, a foundation donated and helped us set up a field hospital with a generator. We now have 50 climate controlled beds and 2 operating areas. We’ve begun hiring a Haitian staff to run the place and are working with the Episcopal Church, who runs the healthcare system in the area, to integrate the facility into their long-term planning for the region. We hope that the field hospital can be used to support them in their mission to provide excellent primary, secondary, and tertiary care to the region. In our first 30 days that we’ve been on the ground we’ve seen approximately 9,000 patients, done hundreds of surgeries, and delivered about 50 newborns.
After having worked with dozens of different physicians since the earthquake and perhaps hundreds of different physicians over the years in Haiti, there are a few qualities that I’ve come to value above all others down there. These include having a broad area of expertise, being comfortable in a chaotic and ever changing environment, having the ability to work with people from diverse backgrounds with a variety of agendas, being able to fulfill a variety of roles, and most of all flexibility. It struck me after one of my more recent trips that these are the same qualities that we look for in our colleagues and our residents in Emergency Medicine. In fact, it sort of sounds like a job description.
I do not want to diminish the role that our colleagues in other specialties have played. There were pediatricians, family medicine doctors, internists, anesthesiologists, obstetricians, and surgeons of many different stripes down there. Many of them have been there for longer than I have and are heroes of mine. They have expertise and experience that I will always envy but never possess. This sort of response would never have happened without them. The only way that we were able to set up that clinic and hospital was by having everyone work together in a coordinated fashion towards a common purpose. Each provider found their role and fulfilled it beautifully. The focus was on what was best for the people living around us; there was no place for politics or personal agendas. There was never any hesitation to lend each other a second opinion or a helping hand. Nobody complained about being woken up at night for an emergency. In some strange respect, it was an ideal of what life could be like in the emergency department.
Nevertheless, as Haiti slowly picks itself up on injured limbs and dusts itself off, emergency medicine physicians have a definite role to play in the rebuilding and bolstering of Haiti’s medical infrastructure. In the near term, there needs to be the provision of round-the-clock emergency care. People still have heart attacks, perforating gastric ulcers, overwhelming infections, and complications from untreated diabetes. Babies are still born every night in the shanties that have been erected in the streets. Many of the NGOs that are working right now board up the doors and turn off the lights after sunset, but somebody needs to care for the sick and the wounded in the off-hours.
More importantly, there is virtually no training in emergency medicine available in Haiti. It is one thing to have physicians volunteering their time to work in Haiti in the short term. A sustainable long-term solution must be Haitian-born, though. Emergency medicine physicians have always been advocates for the poor and the marginalized. I would suggest that our specialty is uniquely suited to assist Haiti, both in the medium-term response to the earthquake, but perhaps more importantly in the restructuring and capacity-building process. We should focus some attention on augmenting the education of healthcare providers, physicians, nurses, and community health workers, in Haiti such that they are better able to respond to natural calamities and every day disasters.
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Medical Relief Mission to Haiti
E. Jackson Allison, Jr. MD, MPH, FACEP
Professor of Emergency Medical Care
Western Carolina University
Past President, ACEP
Shortly after the earthquake, rated at 7.2 on the Richter Scale, hit near Port-au-Prince (PAP), Haiti, I was contacted by the CEO of the Greater Caribbean Energy and Environment Foundation (GCEEF) to ask if I were available to provide emergency care there. I jumped at the opportunity, yet had four firm needs in order for me to commit to going there, plus one definite wish: I wanted assurance of food, water, shelter, and safety; and I hoped for a satellite phone, or something comparable, in order to be able to communicate with the leadership of GCEEF in Miami, and with my wife, Sue, and other members of my family.
It took a week for GCEEF to make arrangements for me to go to PAP, and it took me that long to get my own affairs in order. Although I was originally scheduled to fly out of Miami, I was diverted to Chicago to catch United Airlines Flight 9902, which was a free flight from O'Hare for 165 healthcare workers. Since the flight left at 0700, I had to fly up the night before. What was amazing was that the Hilton O'Hare offered rooms at a discounted rate of $49.00 for this and similar flights to Haiti.
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Greater Caribbean Energy and Environment Foundation Team
Resuscitating a 1-year-old boy who was taken from rubble one week
after the quake and brought to one of our clinics.
Once aboard the 767 craft, the bursar asked that I join her in the front of the cabin. She presented me with many boxes of infant formula, Pampers, medical supplies, teddy bears, and a box of get well cards that had been made by a children's art class in Chicago for the children of Haiti -- all of these things had been donated by members of the United crew. Furthermore, she informed me that a rather large pallet of medical supplies was in the cargo hold, and that that large assortment would be delivered to us at the airport. Needless to say, I was completely undone by their thoughtful generosity.
The scene at PAP airport was chaotic: it took us 2 1/2 hours to assemble all our bags, the extra donated boxes, the pallet of medical supplies, and to be picked up by our host, Dr. Christian Sanon, a prominent, well-respected Haitian physician. We were not required to go through passport control or customs at the airport.
The US military is in control of the PAP airport, and security is very tight. The horde of Haitians outside the fences could see the tons of food and water stockpiled there, and was eager to receive some. More about that later.
After a two-hour bumpy, dusty, harrowing van ride through the pervasive rubble of Port-au-Prince, we had dinner at the home of a Haitian nurse who is a close colleague of Dr. Sanon. It was a delicious meal of beans and rice, the staple of Haiti, and chicken. Little did we know that that was what we were going to be served every night during our weeklong stay in Haiti. The good news is that it was prepared differently each evening.
Our core group consisted of four people: myself, as Head of Mission; another emergency physician, George Poehlman from Fayetteville, NC; George Danenberg, a male nurse from Houston, Texas; and Livio Valenti, a young Italian chap with the UN/FAO, who flew in from Cambodia to join us as our coordinator. We joined up with a larger group from St. Louis, Missouri, which was composed of Haitian Americans led by Dr. Sanon's brother, Franz, who is an architect in the states: three nurses, an imaging tech, a phlebotomist, a nurse’s aide, and a few other medical assistants. We were also melded with a Cuban physician from Miami, and two EMT-Paramedics from Miami and Ocala, Florida, respectively.
Since Dr. Sanon's clinic and a contiguous 4-story hospital had been leveled by the earthquake, he had already established two makeshift clinics before our arrival. One was at the Sports Centre, in the small, dank concrete structure beneath the bleachers of an athletic field/soccer pitch, serving an impromptu tent city on the far side of the field. The other was at Grace Tabernacle, a large open-air facility where it was estimated that 30,000 souls had perished in the quake, and the recent home to another 20,000 Haitians who had set up home in another gigantic tent city. Most of these tents were constructed utilizing four saplings and five bed sheets for walls and the ceiling. People were living side by side in incredibly crowded conditions.
During our week in Haiti, we literally treated hundreds of patients: horrific fractures; challenging wounds; many with understandable anxiety; many with gastroenteritis because the three local wells were contaminated; and hordes of clinic patients who were seeking episodic and routine care because the city was paralyzed.
Three memorable patients: (1) an emergency C-Section performed sans anesthesia by an OB/GYN from the Dominican Republic who just happened to be serving with a group we had joined on our first afternoon of providing medical care. Mother and baby did well, save that we had to pack the mother's uterus and belly with padding and 4X4s and refer her to an overcrowded maternity hospital to be sutured appropriately; (2) a floppy, septic 1-year-old boy who was brought to us immediately after having been dug out of the rubble one week after the quake. We resuscitated him with IVFs via two tibial plateau IOs, IV antibiosis, and an ETT. Were I a betting man that afternoon, I would have wagered that he would not make it; however, after he was delivered by van to an awaiting US Navy helicopter, he miraculously recovered on the US Navy hospital ship in the harbor (the USS Comfort), and was reunited with his family before we departed for the States; (3) a 57-year-old woman with an SBO: again, she was referred to the good ship Comfort, was operated successfully, and rejoined to her family.
Our clinics were crowded, hot, and demanding. Too many patients, not enough staff, and a dearth of appropriate supplies. I sutured a young man's knee with 4-0 nylon sans a needle driver or even a mosquito clamp. Although we had rehydration packets for the infants and children with dehydration, we didn't have adequate clean water to assure that the kids would improve. And although it was in the 90s during the day, it got down to ~ 60 during the night; subsequently, we treated many children with URIs and LRIs. We had not one splint, so we fashioned makeshift splints out of cardboard boxes. We also trained the two paramedics to perform wound care so that we physicians would see many more patients.
Although I've been a physician for 35 years, I had never experienced the penetrating odor of rotting human corpses before: definitely memorable, decidedly disgusting.
It became readily obvious to us that all the people we treated were in need of food and clean water. When we arranged a meeting with the US military to beg for food and water, we were offered anything and everything medical, yet were flatly refused our impassioned request for the food and water... We were told that distributing the latter would just foment riots. We pleaded that we were working with trusted Haitians, and assured the officers that we were willing to take those risks. However, the persistent answer became "Hell no!"
We were able to pry 5,250 tents and enough rice to feed the entire population of the district of Gressier, 30 miles west of PAP, the actual epicenter of the quake, and an area that had yet to receive anything except a modest delivery of fresh water. When we attended a community meeting of Gressier to set up medical clinics there, we announced how proud we were that enough tents to serve 17,000 people had been delivered the day before. However, a mini riot ensued, for we became acutely aware that the tents had been intercepted, and were already for sale on the black market for 200.00 USD. Then a young Haitian announced that although the truckloads of rice had been signed off by the local mayor's office, the rice was now being sold openly in the local market. Our spirits were crushed; corruption is indeed rampant throughout Haiti...
Lessons learned: Corruption is part of the fabric of Haitian culture. Although the US military is in control of the PAP airport, no one is in charge of the city. Downtown Port-au-Prince was damaged the most, and it's where the unchecked looting has taken place. The Haitian government officials are in hiding, refusing to make announcements on TV or radio of what exactly has occurred, and what to expect in the immediate future. The estimated 500,000 people living in makeshift tent cities are experiencing widespread diarrhea, dehydration, and respiratory diseases, including pneumonia. The city is set up for a cholera epidemic. Our medical supplies did not include any tetanus toxoid, splints, or adequate suturing materials. The populace is in dire need of food and clean water. They are also in need of adequate shelter, for the rainy season usually begins at the end of February -- one can only imagine what will become of the flimsy tents once the rains begin. And the people are also in need of established, ongoing medical care. Foreigners cannot hope to get much done sans connections to the Haitian government, no matter how corrupt the latter might be -- that's why working with and through Dr. Sanon was so meaningful; however, because he was nobly trying to be all things to all people, our mission was rather unfocused and diluted, over all.
Now that the acute phase of the disaster has ended, my major concern is who will be there for the long haul of pulling Haiti out of financial and physical rubble??
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Stanford Emergency Medicine and International Medical Corps in the Initial Emergency Medical Response to the Earthquake in Haiti
Paul S. Auerbach, MD, MS, FACEP, FAWM
The following report is adapted in part from a Perspective published at www.nejm.org February 24, 2010 (10.156/NEJMp1001555).
Two days after Haiti's devastating earthquake, a medical relief team made up in part of four emergency physicians (Robert L. Norris MD, Paul S. Auerbach MD, Ian P. Brown MD and Anil S. Menon MD) and four emergency nurses (Gaby McAdoo RN, Heather Tilson RN, Julie Racioppi RN and Jonathan Gardner RN) from Stanford University Hospital and three emergency physicians from Columbia University Medical Center traveled under the auspices of the International Medical Corps (IMC), a nonprofit organization based in Los Angeles, to provide emergency medical support. After an all-night bus ride from the Dominican Republic, the team arrived at the Hôpital de l'Université d'État d'Haiti (HUEH, which is the university hospital) in Port-au-Prince on the morning of January 17. IMC had established a presence at HUEH soon after the earthquake, and during the following week signed a memorandum of understanding with the hospital administration to coordinate the medical activities of non-governmental organizations (NGOs), other volunteer agencies and individuals, and Haitian hospital personnel for the immediate needs of re-establishing services at HUEH.
When we arrived at HUEH, the scene we faced was apocalyptic. Approximately 800 victims were within the hospital compound, most of them outdoors. A damaged building was filled with the patients deemed in greatest need of emergency surgery. Hundreds of patients awaited evaluation and treatment. An internal medicine ward was packed with patients with crush and other severe soft-tissue injuries, amputations, open and infected fractures, compartment syndromes, hemorrhagic shock, and other conditions threatening to life and limb. In a central wooded area outside, there were hundreds of suffering people, many of whom had distorted limbs, maggot-infested wounds, deforming facial injuries, skull fractures, and spinal cord injuries. A single operating room with a few tables was staffed by overworked surgeons who amputated limbs and débrided infected tissue. The morgue was overflowing, and approximately 40 dead bodies were stacked near the medical ward.
For the next 2 days, we practiced continuous battlefield medicine. Working side by side with a few other physicians and nurses, we did our best to evaluate and stabilize every patient. We carried backpacks filled with syringes of injectable narcotics and antibiotics to reduce pain when splinting shattered bones and to treat infections. On the second and third days, access to the country and hospital improved. American, Swiss, Canadian, Norwegian, Haitian-American, French, and Spanish volunteer physicians worked together to improve the situation and bring order to patient flow. On January 20, we were awakened by an earthquake of magnitude 5.9. By the time our team arrived at HUEH, the patients who had been inside the hospital had fled outdoors and new patients had entered the compound. Patients and staff refused to reenter buildings. By midday, the ambient temperature was in the ‘90s and we began to add heatstroke to the list of afflictions suffered by our patients. On that day, we diagnosed two cases of tetanus and many instances of gangrene. Without radiographs, facilities for laboratory tests, or other diagnostic capabilities, all diagnoses were made by physical examination.
Fortunately, on this same day, a U.S. Army battalion was deployed to the hospital. With the arrival of the military, security was immediately established, including gate access, a perimeter surveillance, and crowd control. The soldiers' presence was an altogether positive development for the medical teams. When the U.S. Navy's hospital ship Comfort arrived on January 20, we began to transfer our sickest patients by navy helicopter to a place with more medical personnel, operating rooms, and beds. If we had not been able to transfer patients to the Comfort, many more lives would have been lost.
During the ensuing week, the hospital compound took shape with the addition of more personnel, supplies, tents, rudimentary sanitation and communications, operating room capacity, blood products, laboratory testing and limited radiography, and improved organization and patient flow. By the time that our team departed, nearly two weeks after our arrival, the two-tent emergency department was seeing hundreds of new patients each day.
Emergency physicians were essential to the operations and planning at HUEH. They also practiced at clinics in other areas where large numbers of displaced persons had gathered. The experiences and observations of our team and other emergency physicians, who arrived under the auspices of IMC or other NGOs or university-based teams, or as solo practitioner volunteers, reflect the general nature of this enormous disaster, the realities of disaster medicine and the situation in Haiti. There is much to be learned from what happened immediately after the earthquake and from what continues to evolve in this very unfortunate country.
I agreed to participate in a webinar for ACEP (found at http://www.acep.org/ACEPmembership.aspx?LinkIdentifier=id&id=47835&libID=47863&fid=93211&Mo=No&taxid=117957 ) because I thought that it would be important for all emergency physicians to be aware of the need for their expertise and how they might best become part of the medical response to this and other future disaster situations. For emergency physicians volunteering with IMC or other responders to Haiti, the opportunity was a call to duty by doctors and nurses who are in many ways in the specialty best suited for this type of activity. However, as many learned, even regular practice in a busy trauma center is not sufficient preparation for all of the skills and duties inherent in a disaster response scenario. From clinical skills to what to bring in your duffel bag to administrative leadership, it is useful to know what is in store when you arrive at the scene of a disaster.
Internet links that highlight some of the experience in Haiti may be found at http://abclocal.go.com/kgo/video?id=7240931 (ABC audio interview of me while working in Haiti), http://www.kqed.org/epArchive/R201002080900 (national public radio broadcast about being in Haiti), and http://www.imcworldwide.org/Page.aspx?pid=1119 (brief video interview at University Hospital).
To help improve the understanding of ACEP members and other emergency physicians, I will be presenting an educational session about our experiences and lessons learned at the 2010 Annual Scientific Assembly in Las Vegas on Friday, October 1 from 11 AM to 11:50 AM. I appreciate the opportunity to participate at the Assembly and look forward to seeing many of you there.
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Operational Medical Institute Response in Haiti
David W. Callaway, MD
Co- Director, The Operational Medicine Institute (www.opmedinstitute.org)
Harvard Medical Faculty Physicians, Beth Israel Deaconess Medical Center
Boston, MA
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Operational Medical Institute Response TeamTents.
The January 12th earthquake in Haiti was one of the worst natural disasters in recent memory with an estimated 230,000 killed, 300,000 injured and 1 million people displaced. In addition to the massive medical and public health consequences, the earthquake created significant political and social challenges. Two months out, there is still a desperate need for Emergency and Disaster Medicine specialists.
The Operational Medicine Institute (OMI) deployed to the DR - Haiti border on January 17th at the request of the special envoy to the Vice President of the Dominican Republic. Led by Drs. Alejandro Baez and David Callaway, the OMI team arrived at Jimani with a mission of establishing an Incident Command Structure (ICS) at one of the local hospitals. Working with a diverse group of dedicated but disaster-inexperienced volunteers at the facility, OMI helped empower the ground staff and create the foundations of a functioning medical system.
The ICS system is designed to create a clear chain of command and delineation of responsibilities during a disaster or complex emergency. The power of the ICS lies in its simplicity. There is a clearly identified incident commander and point person for security, logistics, medical operations, administration, and public affairs/ communication. Each leader generally has 5 or less people reporting to them. As staffing expands or new problems are identified, there is a clear reporting mechanism and implementation structure.
When utilized at the onset of an emergency, the ICS is a powerful and common sense operational tool. However, the application, or imposition, of an ICS structure onto an existing organization is challenging. Frequently after an event, highly intelligent though inexperienced medical volunteers pour into the disaster zone. Proper education of these professionals is vital. If done correctly, the results are extraordinary. If done poorly, the maelstrom can cripple relief efforts. One of the keys to OMI’s success was a fundamental belief in empowerment rather than assuming control. By giving the volunteers a skill set, OMI created a sustainable solution rather than a power struggle.
As with most disasters, responding agencies in Haiti face challenges with tracking patients, managing volunteers and organizing supply chains. At the request of the UN and the Pan American Health Organization (PAHO) leadership in Santo Domingo, The OMI initiated the Haiti IT (HIT) Rescue program to address the critical issue of tracking high risk patients. Utilizing off the shelf technology, The OMI worked with private industry, international agencies and academics to deploy iPhone-based patient care and tracking system. To date, the HIT Rescue program has reunited 23 unaccompanied minors with their families, provided Handicap International and the United Nations with follow up information on 40 amputees and helped the Harvard Humanitarian Initiative create a functioning IT system for the field medical facility at Fond Parisien (www.hhi.harvard.edu).
The sixth OMI team is now on the ground in Fond Parisien and in Port au Prince (PAP), Haiti. Though the medical conditions have changed, many of the disaster management issues remain. Reliable logistics and supply chains are scarce. One team is staffing an ICU at a major medical facility in PAP without ventilators, CPAP, oxygen or intravenous fluids. This is six weeks out. As volunteers rotate, continuity of command is difficult to maintain at various sites. And, critical decision making skills are always at a premium.
The recent earthquakes in Okinawa, Chile and Argentina remind us of the critical leadership role that ACEP and the Disaster Medicine Section can play in our nation’s response to complex humanitarian emergencies. We should continue as a professional body to promote best practices, facilitate interagency collaboration and build upon the incredible capacity of our members.
Dr. David Callaway is the Co- Director of The Operational Medicine Institute at Harvard Medical Faculty Physicians. He has a Masters Degree in Public Administration (MPA) focusing on National Security and Disaster Response from the Harvard Kennedy School of Government. Currently, he works as a Clinical Instructor in Medicine at Harvard Medical School and an Attending Physician at Beth Israel Deaconess Medical Center in Boston.
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Rescue, Recover, Rebuild Haiti
Christina Bloem, MD MPH
Robert Gore, MD
Over 80,000 Haitians live in the neighborhood that surrounds SUNY Downstate Medical Center and Kings County Hospital Center in Brooklyn, NY. Haitians compose not only a large portion of the patient population, but also serve as our nurses, doctors, and hospital staff. In the aftermath of the earthquake on January 12, 2010, our healthcare professionals were compelled not just by personal motivation, but indeed by a collective moral obligation to serve their extended family in Haiti during a time of tremendous need.
Supported by EMEDEX International, a non-profit organization that promotes international emergency medicine development and exchange, and coordinated by both the International Division of the Department of Emergency Medicine and the New York Institute for All Hazards Preparedness at SUNY Downstate, a long-term plan for disaster relief was born. The Rescue, Recover, Rebuild Haiti project commits a year-long partnership to provide direct clinical services, resource support, training, and healthcare infrastructure development.
An eager group of 7 doctors and 3 nurses, some of Haitian descent, formed the first team deployed for the Rescue phase of the project. This phase focuses on provision of clinical services, integrated with local existing facilities in Haiti that have staffing needs. The first team worked at University Hospital in Port au Prince, providing 24-hour coverage in the emergency department, which previously had been limited to no night-time staffing.
With an influx of approximately 600 patients per day, the team jointly coordinated with local staff an emphasis on registration and triage to manage the workload. The EMEDEX team also made a simple and very effective change to the emergency department with the addition of a fast-track area. This absorbed a huge volume of patients, decompressing the other ED areas and enabling them to attend efficiently to more critical complaints. The Haitian Creole-speaking members of the team allowed for increased self-sufficiency and cultural integration.
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Rescue, Recover, Rebuild Haiti Project Team Caring for a
Wound Infection
The first trip emphasized the need for a long-term commitment, as the complex layers of challenges to rebuilding were revealed. Resources – medications, supplies, and staff – were not only limited, as expected, but also inconsistent. Inpatient, intravenous treatment of malaria might be feasible one day, but unavailable the next.
Communication was challenging at times, and occasionally posed a barrier to patient care. Walkie-talkies used by logistics personnel sometimes allowed ED physicians to reach specialty consultants on-call, although more often, consults required walking over to that particular ward to find the appropriate person. Language was not as much of an issue due to the availability of many Haitian-Creole translators at the hospital, some of whom were local high school students and medical students from University Hospital itself. However, inter-departmental, inter-facility, and local community communication were problematic.
The hospital, and the country as a whole, had multiple NGOs present, all attempting to coordinate their efforts under the difficult mesh of varied approaches and mission statements. Sometimes this worked and sometimes it didn’t. In an attempt to improve communication and organize humanitarian response, the United Nations created the "cluster" system in 2005. Nine clusters were formed (one of them designated for Health), each composed of representatives from the UN as well as other NGOs. This system was rolled-out for the first time just last year, in Timor-Leste, and its effectiveness is still being evaluated. The EMEDEX team participated in the Health Cluster meetings of Port au Prince to better streamline their work with other active players in the healthcare relief.
Patient privacy issues became apparent in the setting of crowded tents and limited space. History-taking was significantly compromised, with a decreased ability to screen for domestic violence or discuss other sensitive information. Physical exams were limited by these constraints as well, with draping providing the only form of privacy.
Credentialing of healthcare workers poses a problem in any disaster situation. Groups coming to work in Port au Prince were required to register, but individual qualifications were not centrally verified, leaving each organization responsible for its own members. To overcome limitations in human resources, the EMEDEX team implemented on-the-go task-shifting strategies, employing the "see one, do one, teach one" philosophy common to medical training programs.
Finally, the importance of evidence-based humanitarian response revealed itself through the unintended consequences of groups "trying to help." Though providing free healthcare and free medications seems ethically appropriate and necessary, many pharmacies and local physician offices closed as a result of decreased business. Continued needs assessments and post-response evaluations must be used to avoid imposing a burden on the local economy and infrastructure. A focus on integration with local resources, building capacity, and sustainability must remain central to any organization’s approach.
The Rescue phase still holds two more trips to focus on direct provision of care related to the earthquake victims. Following that, starting in June, the project will begin its Recover phase, where the team will not only provide patient care, but will transition into addressing more long-term goals such as healthcare provider skills training, health facility capacity building, and creating links with the larger healthcare system. The year-long project then finishes with the Rebuild phase, which will create the foundation for continued healthcare rebuilding, a process which undoubtedly will require several years of work to come.
For those interested in collaborating with the long-term medical relief and rebuilding efforts in Haiti, contact Dr. Christina Bloem , Dr. Robert Gore or see the EMEDEX International website at www.emedexinternational.org.
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Schneider Regional Medical Center Response in Haiti
Selwyn Mahon, MD, FACEP
US Virgin Islands Ems Medical Director
US Virgin Islands Medical Reserve Corps Director
Schneider Regional Medical Center
On Saturday January 16, 2010, the Schneider Regional Medical Center on St Thomas, U.S. Virgin Islands sent its first medical team to Haiti with more than 2,200 lbs of donated medical supplies. Their original mission was to support a UN field hospital at the airport. However when the team arrived they found the field hospital overwhelmed by patients and volunteers. The hospital was unable to accommodate any more volunteers. The team decided to leave the airport, and find a place where they could help. With the assistance of their local contact the team established a base of operations at L’Hopital de la Communauté Haitienne, or Haiti Community Hospital, a 50-bed hospital in the Fréres Neighborhood of Petion-Ville.
That first team proved to be instrumental to the success of other volunteers that came to that hospital. During their first 4 days they were able to transport supplies from the airport to the hospital, and establish an inventory, storage, maintenance, and distribution system for our supplies and medications. They initiated a system for registration and orientation of incoming medical personnel, translators, and other volunteers. The team also partitioned a "tent city" sleeping area for staff which provided the tents and air mattresses and were able to perform over 140 operations including amputations, external fixator stabilization of fractures, a Caesarian section delivery, and three live deliveries.
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Schneider Regional Medical Center Response Views of Destruction.
On Monday January 18 and Tuesday January 19 another team from Schneider Regional Medical Center was sent to replace the first team. I was part of the team that arrived on the 19th. After being briefed by the first team, we unloaded the plane packed with supplies and with the help of our local contacts we were taken to the hospital. We deposited our supplies and within an hour began caring for the injured Haitians. The majority of our team was assigned either to the Operating Area or the Recovery/ICU area. I functioned as the physician in the ICU/Recovery area. I also was assigned a cache of medications by a pharmacist who left the first day we arrived, so I functioned as the pharmacist for a while.
In Haiti we witnessed indescribable destruction, and the suffering was immense. There were rooms after rooms, and corridors filled with suffering injured Haitians. We witnessed deaths that would have not occurred in the most rudimentary of hospitals but due to the lack of simple medications or equipment we were helpless to save them. The hospital operating room was in use 24 hours daily with surgeons from the Virgin Islands and other parts of the United States, France, Sweden, Japan, Hungary and Jamaica all doing their best to save lives. There were many limb amputations both of adults and children and some of the wounds became infected causing further amputations, sepsis and death. Every day we received more supplies and our capacity to care for our patients improved. We were constantly thanked by our patients, the local staff of the hospital, as well as the public for our help. At no time were we physically threatened.
Every day the needs of the hospital changed. We also witnessed the subtle change clinically as the care transitioned from disaster/emergency medicine to more of a traditional hospital type care. There were women in labor, uncontrolled diabetics and hypertensive patients. We treated empirically an angina/ myocardial infarct patient (we could not differentiate since we did not have EKGs). We were now treating Haitians without earthquake related medical problems. Our team left Haiti at midnight January 23rd exhausted, with an overwhelming feeling of accomplishment but with the knowledge of how great the need was for continued medical assistance.
As I reflect on the time spent in Haiti I noticed that there was a significant absence of the Incident Command System. I also noticed that the teams that were most effective were self sufficient with clear objectives and plans. There were many non-disaster trained medical volunteers. Some of the teams that arrived did not have local contacts, and spent significant time setting up operations. In Haiti, as it is in all disasters, coordination of personnel and communication were significant problems.
I was awed by the gratitude of the Haitian people and the unselfishness and altruism of the volunteers. I was inspired by the cooperative spirit of volunteers from all over the world who came to Haiti and worked together with the sole purpose of providing humane compassionate care to people subjected to such a calamity.
After my experience in Haiti, I am conflicted by the concept of volunteers who self deploy. Usually disaster medicine does not support this practice but it is clear that the structured response often takes awhile to be established. I witnessed many lives that were saved by these brave volunteers who placed their life in danger to respond before established safety zones were created. If it were not for this group of volunteers who self deploy and venture in when rational professionals would urge caution, what would happen to the critically injured during the most immediate phase of a disaster?
For further information on the Virgin Islands Haitian response click on:
http://www.usvihaitianrelief.org/home
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Revival from the Rubble
Michael Connelly, MD, MPH
Her gaze was distant; she looked away, towards the dusty, rock-strewn ground that was the floor of our emergency department. She spoke softly as she told us how she reentered her home to help one of her younger siblings outside to safety. It was soon thereafter that a wall collapsed, trapping her by crushing her left arm. After some time she was able to grab a knife that was within reach and the 14-year-old girl cut what was left of her arm off so that she could live another day as her younger siblings’ protector. The translator assisting me and I were stunned and humbled by the bravery of this Haitian girl who seemed to know the line of life and death all too well for someone her age. It is a harsh reality the Haitian people are living, and though you look at rubble and the tent cities and the extremely sick patients before you, you see the resiliency of a people that admirably move forward.
I arrived in Haiti on February 6th, post-quake day 25, and settled into my position as emergency physician at the Project Medishare field hospital. That hospital was a true testament to the tireless efforts of faculty from the University of Miami to establish a positive presence in Haiti even before the earthquake. By the time of my arrival it was an impressive array of large tents with a functioning operating room, four bed ICU, and inpatient pediatric and adult wards. We had x-ray and fluoro capabilities and by mid-week, laboratory medicine was giving us chem-7, cbc, rapid HIV, ABG, and malaria smear reports. The emergency department was under a smaller shelter with a collection of 10-12 cots, but later in the week we did get hold of an exam table and used it to set up a resuscitation bay that was used frequently.
The morbidity was most certainly in transition from the pathology seen in the first days post-catastrophe. Most of the acute care seemed to be complications of the earthquake as opposed to a direct result from it. A lot of the orthopedic injuries we were seeing were already fusing in their displaced and angulated states, but as four-week injuries, were simply left alone. The ones that were taken to the OR were wound or hardware infections from previous surgeries, many from other field hospitals.
The newborns are an unfortunate display of secondary impacts of a disaster, as many that were brought in were incredibly malnourished. Two-month-old babies on mango and papaya paste because the mother was killed in the quake or trapped beneath the rubble for enough days that her milk stores ran dry. The Haitians left to care for these children do not have milk to provide and they have no resources to get formula much less the ability to purify water if they did have the powder. The circumstances of these failure to thrive babies is heart wrenching.
No matter what the chief complaint, it seemed all patients presenting to our emergency department related their current health issues to the terror of January 12th. Older patients in florid CHF or HIV patients with opportunistic infections running rampant as they lost access to chronic medications to keep their illnesses at bay. Dehydration from gastrointestinal illnesses or just plain malnutrition is causing a lot of morbidity, particularly in the elderly. Malaria and dengue are also taking their toll and was likely responsible for at least one in-hospital death during my stay. Trauma from assault is definitely prevalent, but not having worked in Haiti before it is difficult to know if this or any of the secondary morbidities in the wake of the temblor are above the norm for the region.
Wound care is an ongoing problem and patients becoming septic from those wounds put a strain on the resources available. Aggressive wound care at our facility, often with conscious sedation, and the diligence of many Haitians to make the frequent, arduous journey to our encampment was preventing many severe systemic infections. One 4-year-old still had the galea visible overlying his skull but the soft tissue looked fantastic.
Before I arrived to Haiti I would never have imagined that I would be taking care of someone pulled straight from the rubble. Search and Rescue crews typically stop after about one week. Hearing of the Haitian girl pulled out alive after 15 days I said to a colleague, "Can you imagine being trapped in the rubble for 2 or 3 weeks, and the last sound you hear is a bulldozer?" Then, on a typical Monday, with everything in the ED falling apart at the seams and dozens of people waiting for treatment, an ambulance delivered a young gentleman who had just been extracted from the ruins of a marketplace after a 27 day burial. He looked as though one simply stretched skin over a skeleton except for some facial definition and swelling of his feet that were likely crushed and now infected. We began the task of gentle rehydration and antibiosis to stave off an impending sepsis. These young miracles have definitely set an argument for extending search and rescue operations far beyond a seven-day window. The will to survive and move forward is clear and present in the Haitian people, and it pushed this man through his delirium until his arrival and recuperation at our hospital.
The next day I went on a brief tour of Port-au-Prince with one of the other NGOs that had based itself with Project Medishare. The destruction was unfathomable and outside the tent cities the piles of garbage and refuse were a harbinger of the infectious epidemics likely to follow. It was still so hard to believe that a man had been found alive in all that collapsed concrete and twisted rebar just a day before. What was most impressive were all the Haitians on the street, walking with purpose, or cleaning, or still digging through the collapsed walls and roofs of buildings and homes. Such devastation that killed and maimed relatives and neighbors, destroyed their homes and businesses, laid waste to architectural symbols of national pride, yet thousands of people are moving about the city and likely the countryside, with the conviction that today will be a better day than the one before.
With political strife, hurricanes, and now a 7.0 magnitude quake in their nation’s capital, it is difficult to argue that there is a nation more emblematic of the Greek figure Sisyphus, than the nation of Haiti. Seeing so much illness, so much destruction, it is easy to feel that the task at hand in Haiti is one that is insurmountable. Undoubtedly for many of the survivors, they have similar sentiments at times. Nonetheless, it is an honor and privilege to serve the people of Haiti as a member of the International medical community. The challenges are undeniable and the situation will remain dire for months, if not years to come. As members of the human race we have a humanitarian obligation to assist the hundreds of thousands of our island neighbors who are in need. However, after hearing the voice of that 14-year-old amputee and seeing the resolve of the Haitian people in a time of such adversity, I do believe that some day they will push that boulder up to the top of the mountain, and there it will stay.
Transportation to Haiti, as well as living and working facilities, was provided to the author by Project Medishare through the University of Miami. Anyone interested in learning of volunteer or financial donation opportunities through the organization are encouraged to visit the Web site: http://www.projectmedishare.org
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Haiti: Beneath the Rubble
Nedal Shami, MD
Department of Emergency Medicine
The Valley Hospital
Ridgewood, NJ
Initial Experience:
We returned from Haiti late last night. The situation there is quite bleak, the problem goes far beyond the earthquake however, it certainly has made things exponentially worse. We went down with Our Chance International / Nova Hope. This group placed us with Medishare, a large NGO associated with the University of Miami, who has been operating in Haiti for the last 20 years. When we arrived we were stationed at a field hospital set up within the airport grounds that was surrounded by the US military and UN. It was actually a semi functional site, with an ER/Triage, OR, Med, Ped, Wound Care, Pharmacy and a single portable x-ray machine. I put myself where I felt most comfortable, the ER of course, and we would basically stabilize, treat and release, admit or transfer all incoming pts.
Our transferring option was to the USS Comfort, a Navy hospital ship, which was a fully functional hospital. This option was actually very difficult and many patients wouldn't actually make it to that point. The patients that were simply too sick/poor prognosis or required isolation would be separated from our inpatient area and placed in "tent city" - an isolation area with about 10 mini tents where the soon to be deceased would be placed for comfort care. One of my patients actually spent about 40 hours in agonal respiration until she passed. She was a presumed pontine stroke, came in unresponsive, hypertensive 260/140, with pinpoint pupils. I decided not to intubate her, as I did not want to lose our last vent slot. We called these patients NQR (non quake related). A majority of our patients were quake related (fractures, crush injuries, head trauma, and wound infections). However, by Saturday night we started getting more and more NQR patients, including a couple of GSWs to the head and face. Apparently some gang violence began to erupt outside of our walls for food and water.
A majority of cases were ortho related; man those guys got killed, an average of 25 cases a day between 3 orthopods and only 2 real OR spots. There was another area where amputations occurred. This was under local anesthesia and did not take up an OR spot usually. I must say that under the circumstances we all worked very well together. On average everyone worked about 18-20 hour shifts, took mini naps and came back.
Now I know why they only wanted 5-day commitments. We only did 4. I think I could have done 1-2 days more at most, but the flights out began getting really shady as people were waiting 1-2 days to get out! So we decided to leave a day early. Basically the charter flights that were all donated initially began drying up, and our camp said all Sunday flights that were scheduled were cancelled and the Sunday list of departures would be bumped until Monday, Monday until Tuesday and so on. This got us a little uneasy as many of us had to be back, either for work, families, or simply shear exhaustion. So we decided to make an early run to the airport as we heard the US air force would "evacuate" Americans on their C-17 military transport ships. These things were HUGE! We got to the airport at about 4am as we heard the lines out could be up to 12 hours long. The big advantage we had was that we were within the airport grounds and that it was a "safe" 5-minute drive. Everyone else from the different camps around Haiti had to wait until sunrise to get there because no one drove at night, as it was dangerous to even step outside of the walls. One night someone threw a body over the outer walls. We never figured out if this person was killed and thrown in or if somebody wanted to get a family member in for medical aid because the Army would close the outer gates and stop allowing patients in when we were over stretched. In any case, we arrived really early at the airport and got on a military cargo flight about 6 hours later. The best is that they don't tell you where it's going until you take off, US Air Force security reasons! There were no seats left so they sat us in rows of 4 and strapped us in with the cargo belts. I have a picture of this and it's kinda funny. I arrived home in NY 15 hours later. Not bad for a 2 1/2 hour flight!
This story can't be allowed to fade away. Public interest/awareness is crucial as it drives funding and support. Continue to spread the word! Attached is a Flicker link to select photos from our trip.
http://www.flickr.com/photos/21077453@N07/sets/72157623205602805/
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Our Chance International Patient Care in Haiti.
Current Reflections:
I have had some time to reflect since my trip and I think the effects of what we witnessed are just starting to sink in.
The devastation witnessed has been replayed on every news outlet across the country, yet the actual trauma and suffering goes much deeper than a picture could capture or attempt to reproduce. The level of human suffering witnessed is difficult to articulate, it leaves a permanent mark that serves as a constant reminder, a reminder of our fragility, our fortitude, our empathy, our sense of humanity. The depravation and suffering in Haiti clearly began before the earthquake; that was one of the most profound realizations for me. What seemed to be a level of incredible resilience may have been slightly tempered by a degree of indifference. That's a hard pill to swallow; for us the destruction and pain was so vast and far-reaching, so devastating and unthinkable. Yet for the people of Port Au Prince I believe the contrast was not so stark. I plan on returning to Haiti soon. I hope to continue the work I started; more importantly I hope this event sheds a fixed light on the situation there, so that meaningful changes occur. I hope our initial efforts go beyond the Band-Aid we have temporarily placed.
Ways to Help:
I hope the effort there continues, and that we all give whatever we can (money is the best way to give http://www.ourchanceint.org. OCI is the organization that sent us; or use any charity that you know and trust. God knows they need it. OCI is an amazing charity, cofounded by Sue Vallese, who is a remarkable woman that has put her heart and soul into helping children all over the world. Please give now if you haven’t already.
Medical staff that is seriously interested in volunteering with OCI can e-mail me and I will help you coordinate with Sue Vallese, as the requirements on the ground are rapidly changing. The needs in Haiti will be measured in years, not days or months.
Acknowledgements:
Thank you Christen Parker, Joe and Pat Parker for putting us up and allowing us to take over your home! Thanks Marisa from Project Medishare, thanks to Dr. Joseph Yallowitz for your support and covering my shift, thank you Sue Vallese for everything, everything and everything, thanks Dr. Alan for finding and bringing in that kid, I known it took you all day to get to us! Yaniv - you are the man, thanks for being you! Mat and Ryan - Get home safe guys, the ED wouldn't have been the same without you! If you guys have Tim, the ED charge RN info please send to me!!! And Ryan from OCI/Logistics - thanks for taking care of us down there, you are a remarkable young man.
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One Responder’s Perspective on Haiti and the International Relief Effort
John Broach, MD, MPH
The death toll, the physical destruction and the societal cost of the earthquake in Haiti on January 12th are unprecedented. By many measures that event will likely be recorded as the worst natural disaster in modern history. I had the opportunity to travel with a team of medical providers from the University of Massachusetts and accompanied by other clinicians and logistics personnel from International Ministries, an NGO working in both the Dominican Republic and Haiti. Our mission was the treatment of patients living in tent camps around Port-au-Prince during the third week after the earthquake.
This was an interesting environment and time to be working in a responder role as acute injuries were being replaced by conditions of long term displacement as the primary health concerns. From the perspective of a responder, our team also had an effective approach that should be replicated in future events and in an ongoing basis in Haiti as time goes on and people continue to live in tent camps.
Our team traveled each day to tent camps in Port-au-Prince, set up areas for consultations with patients, a pharmacy, and registration area, and was able to treat 200-300 patients per day. Our pharmacy included basic analgesics, antibiotics, antimalarials, oral rehydration solution, and nutritional supplements. All of this was packed up and moved back to a staging area where the team was housed at the end of each day and a new camp was visited the next day with subsequent teams visiting a limited number of camps on an ongoing basis. We began this work on day 15 post earthquake and many of the people we encountered had not yet received relief services of any kind. This is not to impugn in any way the massive effort which has been undertaken to this point in Port-au-Prince. In fact, although much more needs to be done and there will continue to be hard work to do for some time in Haiti, it must be acknowledged that there was a very significant international presence and resources continue to arrive in Haiti now.
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International Ministries Team Tent Camp
The experience of our team, however, makes two important points that arise in almost every international response to large scale humanitarian crises. The first is that small NGOs, outside the United Nations and World Health Organization system make valuable contributions. The second is that the more that the international aid community, particularly through the UN cluster system can roll in the efforts of small NGOs the more effective the overall response will be. The UN cluster system, as organized by the UN’s Inter-Agency Standing Committee is the international answer to unified command under the American Incident Command System. While this system shares the modularity and scalability of the ICS, it lacks the authority to ensure that all resources are being used as effectively as possible and that duplication is minimized.
International disaster response obviously has layers of complexity which make the American system not directly applicable, and many other systems exist worldwide for coordinating response. What is constant, however, is that the more coordinated the efforts of individual agencies are, the more effective the response. Although many organizations are cooperating on the ground in Port-au-Prince, much of this cooperation is organized on an as needed basis and in the midst of the response. The Haiti earthquake gives us a clear example of a large scale humanitarian catastrophe from which we can learn and structure the next response. The key to true improvement may well lie in strengthening the spirit of coordination embodied by the UN cluster system and in the acknowledgement that the effort is made stronger as more small agencies with specific capabilities and areas of expertise are brought into the process.
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Preparations for My Medical Relief Trip to Haiti
Ashley S. Bean, MD, MA, FACEP
Like many of my fellow ACEP members, I watched news of the events in Haiti with the feeling that my skill set as an emergency physician would be of great assistance in the aftermath of the earthquake. While I have participated in medical mission trips and have seen abject poverty, my disaster relief experience thus far has been limited to local disasters in which I served as an emergency physician. In Arkansas, disaster is usually equated with an unruly tornado, and I have taken care of mass casualties at a level one trauma center during several of these storms. Mass casualties are actually comprised of individuals and what we as emergency physicians excel at is simultaneously taking care of multiple individuals with diverse problems.
After determining that I could be of use, my next step was finding an organization with which to travel and work. As I listened to the reports of disorganized medical care, I wanted to ensure that my trip would be successful. I felt that a group that was familiar with Haiti would be more likely to have the best local infrastructure and connections. Various inquiries led me to Partners in Development. This organization has two clinics in Port-au-Prince and has been working in Haiti since 1990. During my first conversation with this group, the US organizer remarked, "Your skills as an emergency physician will be very useful. I want to get you to Haiti as soon as possible." I remember thinking, "No one wants to hear from the ED doctor…. unless there is an emergency, and then we are everyone’s best friend." Another positive attribute of Partners in Development is that they are able to supply food and drinking water for the duration of the trip. Other groups I contacted suggested that I bring a week’s supply with me; therefore, decreasing the amount of medical supplies that I could carry.
My next steps involved arranging to take time off from work while gathering medical and personal supplies. In each aspect, I received an incredible amount of support. I am fortunate to work with a fantastic group of physicians at the University of Arkansas who were more than willing to cover my shifts, making this the easiest step in the process. Next, I ordered medical supplies from Medical Assistance Programs (MAP) International and Blessings International. Both organizations were responsive to my needs and expedited the medication shipments. In addition, my sister-in-law, who has been to Haiti on numerous occasions, put her MPA degree to good use and gathered donations from her friends and fellow church members. Furthermore, the volunteer clinic I work in a few nights a month donated its expired medicines which are welcomed in Haiti. On the personal supply side, I will be living in a tent for the duration of the trip. A friend contacted The North Face which donated a two person tent for me to use. With this type of help, I was able to quickly gather a sleeping bag, sleeping pad, and clothes for 95 degree weather. In short, while I may be the person actually traveling, this trip is the result of the work and generosity of a network of individuals.
After making arrangements for luggage and equipment, it was also important to ensure that I travel as safely as possible. For this type of advice, I consulted the CDC website. Their first recommendation for travel to Haiti is, well, simply not to go for nonessential travel. For relief workers, recommendations include being vaccinated against typhoid, and hepatitis A along with being up-to-date on routine vaccinations (i.e. tetanus, H1N1, seasonal flu, MMR, hepatitis B). In addition, malaria prophylaxis and protective measures against mosquitoes are important to prevent the spread of malaria as well as dengue fever. For anyone considering a medical trip to Haiti, there is a wealth of information on the CDC website about common infections, key items to pack, safe food and water practices, heat-related illness prevention and expected psychological effects. In addition, Partners in Development has sent briefings so I have some information on current conditions in Haiti. Several teams have rotated through their clinics and have seen both long-standing health issues (hypertension, diabetes mellitus, anemia and malnutrition) that have been exacerbated by the post-quake conditions, as well as infections (respiratory, soft tissue and malaria) that appear to be on the rise as people live in crowded conditions.
So, now my clothes are sprayed with Permethrin, I am taking Chloroquine, I have received more vaccinations in the past few months than a 12 month old and my bags are packed with 100 pounds of medicines. I just need to catch that 5:30 am flight.
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Gheskio Field Hospital In March
Mark Hauswald, MD, FACOG
Professor of EM and Co-Director of Global Health Programs at University of New Mexico, NM1 DMAT
Half the city turned to fist sized rubble;
Half the people in tents pitched in mud;
Endless lines of new amputees;
Rain bringing malaria and dengue;
But children washed in buckets before clinic;
Woman in spotless white dresses from camp;
New mothers eating MREs;
And newborns sleeping in the rain;
It will not be over for years…
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Updates
Marshall Gardner, EMT-P
Manager, ACEP EMS & Disaster Preparedness Department
- The Disaster Medical Services Section Membership count is currently 441.
- The 2010 Leadership and Advocacy conference will be held May 16-19, in Washington, DC.
- The 2010 Integrated Training Summit will take place May 12-16, in Nashville, TN
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2009 - 10 Disaster Medicine Section Officers
Stuart B. Weiss, MD, FAAP, FACEP
Chairman
Dr. Weiss is the CEO of MedPrep Consulting Group LLC, a consulting firm providing disaster preparedness and business continuity consulting to domestic and international corporations. He is also a physician surveyor for the Joint Commission Hospital Accreditation Program. Prior to his current position, he was the director of the Center for Healthcare Preparedness at the Saint Barnabas Health Care System, the largest integrated health care system in New Jersey. He has over 20 years of experience in pediatrics and emergency medicine and over a decade of experience in planning, training, exercising and education in areas related to disaster preparedness, hazardous materials, and the consequences of man-made and natural public health emergencies.
Ramon W. Johnson, MD, FACEP
ACEP Board Liaison
Current Professional Position: Associate Director, Emergency Department, Mission Hospital Regional Medical Center, Mission Viejo, Calif.
Residency: UCLA Health Sciences, Pediatric Residency (1982); Emergency Medicine Residency (1984)
Years Elected to Board: 2004, 2007
Bio: Dr. Johnson is associate director of the emergency department at Mission Hospital Regional Medical Center in Mission Viejo, CA. Over the course of his 25-year ACEP membership, Dr. Johnson has served on several committees, including the Bioterrorism Task Force and as chair of the State Legislative/Regulatory. He currently serves as liaison to the Emergency Medical Service (EMS) and Pediatric Emergency Medicine Committees, the Disaster and Aeromedical Sections.
At the state level, Dr. Johnson was past president of ACEP's California Chapter where he chaired the EMS Committee and Bioterrorism Task Force. He is a member of the State's Joint Advisory Committee on Preparedness which was responsible for developing the state's strategic plan for disaster preparedness and response. He is the past chair and still a member of the California Commission on Emergency Medical Services. Dr. Johnson is the co-chair of the EMSC committee and former chairman of the Trauma Advisory Committee, which initiated the process for creating a statewide trauma plan.
Andrew M. Milsten, MD, MS, FACEP
Immediate Past Chair
Andrew Milsten completed his medical school training at the George Washington University medical school. Dr. Milsten trained in Emergency Medicine at Lincoln Medical and Mental Health Center (Bronx. NY), after which, he completed a 2-year EMS/Disaster Medicine fellowship and EHS masters degree at the University of Maryland. While at University of Maryland, Dr. Milsten focused his research on mass gathering medicine. Dr. Milsten has worked overseas as a visiting scholar and EMS consultant to Prishtina, Kosova (July 2001) for John Hopkin’s ER Development Project as well as an emergency preparedness/disaster medicine trainer in Amman, Jordan (October 2005) for University of Maryland’s NIH/Iraqi MOH sponsored program. Currently, Dr. Milsten works at University of Massachusetts in the emergency department and is the Disaster Medicine and Emergency Management Fellowship director.
Ira R. Nemeth, MD
Vice Chair
Dr. Ira Nemeth graduated from George Washington University School of Medicine and has completed a fellowship in Government Emergency Medical Security Services at the University of Texas Southwestern Medical Center at Dallas (UTSWMC). He recently left his position as the Medical Director for Public Health Preparedness for Dallas County Health and Human Services to take a position as Director of EMS and Disaster Medicine with Baylor College of Medicine. As an Assistant Professor, he works as an Attending Physician at the busy Ben Taub Emergency Center. Dr. Nemeth is a member of The Texas Governor's EMS and Trauma Advisory Council Committee on Disaster / Emergency Preparedness. He also serves on the State of Texas Incident Management Teams Steering Committee. Dr. Nemeth also serves on the Disaster Preparedness & Response and EMS Committees for The American College of Emergency Physician.
Joseph Sabato, Jr., MD, FACEP
Secretary
Dr. Sabato is an Assistant Professor of Emergency Medicine at the University of Florida Shands-Jacksonville and serves as the facility Disaster Medical Officer. Dr. Sabato is the Director of Field Operations for the Department of Emergency Medicine and oversees the EMS rotation and preparedness training for the emergency medicine residents. Dr. Sabato also participates in the medical response team for NASA Space Shuttle launches and landings. Dr. Sabato previously practiced in New Hampshire and Massachusetts with extensive experience in public health preparedness and emergency medical services. In addition to disaster preparedness current interest and involvement include emergency public health and induction of hypothermia post cardiac arrest.
Henry A. Curtis, MD
Newsletter Editor
Dr. Henry Curtis graduated from Louisiana State University Medical College and will complete an emergency medicine residency at Mount Sinai School of Medicine in June 2010. He is an active member of the New York City Medical Reserve Corps. At Mount Sinai, his specialty tracks are Disaster Medicine/EMS. His research is focused on disaster medicine training modalities. He is currently developing a video-based disaster medicine curriculum at his institution.
Eric S. Weinstein, MD, FACEP
Newsletter Advisor
Eric S. Weinstein, MD FACEP is an undergraduate of Tulane University (’83) and Rutgers at Camden Medical School (’87). His career in Emergency Medicine started at age 16 with the Rockaway Neck Youth First Aid Squad in Lake Hiawatha, N.J. After an Air Force Sponsored Emergency Medicine Residency at Metropolitan Hospital (’91), a New York Medical School Affiliate, he completed his tour with the Air Force at Malcolm Grow Medical Center (’93), Andrews Air Force Base (Md.) and as Clinical Assistant Professor of Military and Emergency Medicine at the Uniformed Services University of the Health Sciences (USUHS).
Migrating to South Carolina, in Florence as Associate Medical Director of Trauma and Emergency Medicine at the Carolinas Hospital System, he was instrumental in developing the first ACS Level II Trauma Center as well as reviving the NDMS SC-1 DMAT as Team Leader. Over the past ten years, he has been the ACEP Section of Disaster Medicine Newsletter Editor, Chair and currently is a member of the ACEP Disaster Preparedness and Response Committee.
Christopher S. Kang, MD, FACEP
Web Site Editor
Research Coordinator - Madigan Army Medical Center EM Residency Program
Attending Physician - Madigan Army Medical Center Department of Emergency Medicine
Dr. C. Kang was raised in Honolulu, Hawaii and the United Kingdom before attending Northwestern University Medical School, followed by a residency in Emergency Medicine also at Northwestern University in Chicago, Illinois. He is certified by the American Board of Emergency Medicine and a Fellow of the American College of Emergency Physicians (ACEP), as well as a member of the Wilderness Medical Society (WMS) and the Society of US Army Flight Surgeons.
Dr. Kang has been an Attending Physician at the Madigan Army Medical Center (MAMC) EM Residency Program since 2001, first while serving on active duty from 2001-2004, and now as a civilian staff member. While on active duty for the US Army, he participated in several large scale mass casualty exercises, was assigned as a physician member of the Western Regional Medical Command NBC Special Medical Augmentation Response Team, and chaired the creation of a new hospital emergency patient decontamination protocol. He is currently the Research Coordinator for the MAMC EM Residency Program as well as a Clinical Assistant Professor at the University of Washington. He has also recently served on the MAMC Pandemic Influenza planning committee and published several articles on various communicable diseases. He is the 2002 recipient of the MAMC EM Residency Outstanding Staff Teacher Award.
Marshall Gardner, EMT-P
ACEP Staff Liaison
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Mr. Gardner began his EMS career in September of 1986 as an Emergency Medical Technician, and finished paramedic training in 1990. He graduated from the University of North Texas in 2004 with a degree in Emergency Administration and Disaster Planning.
Mr. Gardner has worked in Dallas/Fort Worth in private EMS. He worked for MedStar Emergency Services, in Fort Worth, as a paramedic, preceptor, Field Training Officer, System Status Controller and Mass Casualty Incident team member. He also served as a part-time faculty member for the Weatherford College Paramedic Program. From 1996 to 2003, he was a flight paramedic and clinical base manager for CareFlite Air Ambulance.
After graduation from UNT, he worked in local municipal government as an emergency manager. During this time, he worked on three presidentially declared disasters, including Hurricanes Katrina and Rita.
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