Dispatch from Port-au-Prince--January 27, 2010

Tuesday, January 26, 2010

HAITI'S SHAMEFUL MEDICAL STATE

The young lady pictured to the right is Mona. She lives in southern Haiti and has the most common cyanotic congenital heart disease called Tetralogy de Fallot. Most people with heart defect do not make it out of their teenage years. Mona, being Haitian of course, survived. She needs surgery and I am looking for a medical center in the States to accept her.

Please help if you know of a good medical center that would operate adults with congenital heart disease.

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Below is a commentary written from the heart by a team of doctors that found the medical situation in Haiti after the earthquake worse than they could imagine.

Doctors: Haiti Medical Situation Shameful

By Drs. Dean Lorich, Soumitra Eachempati and David L. Helfet, Special to CNN

Doctors gathered sophisticated team and equipment for Haiti on private plane.

They found nobody in charge, chaos, hospitals had nothing, not even elementary equipment. Plane sent with equipment; supplies hijacked; resupply plane not allowed in. They say the "lack of support for our operation by the United States is shocking."

Editor's note: Dr. Dean G. Lorich is the associate director of the Orthopaedic Trauma Service at the Hospital for Special Surgery and New York Presbyterian Hospital and teaches orthopedic surgery at the Weill Medical College of Cornell University. Dr. Soumitra Eachempati is a medical researcher with a clinical surgical practice and teaches at Weill Cornell Medical College. Dr. David L. Helfet is professor of orthopedic surgery at Weill Cornell Medical College and director of the Orthopaedic Trauma Service at the Hospital for Special Surgery and New York-Presbyterian Hospital.

New York City (CNN) -- Four years ago, the devastating Hurricane Katrina affected millions in the United States. The initial medical response was ill-equipped, understaffed, poorly coordinated and delayed. Criticism was fierce.

The response to Haiti has been the same. The point no one seems to remember is this: Medical response to these situations cannot be delayed. Immediate access to emergency equipment is also crucial.

Within 24 hours of the earthquake, Dr. David Helfet put together a 13-member team of surgeons, anesthesiologists and operating room nurses, with a massive amount of orthopedic operating room equipment, ready to be flown directly to Port-au-Prince on a private plane.

We also had a plan to replace physicians and equipment -- within 24 hours, we could bring in whatever was necessary on a private jet. We believe we had a reasonably comprehensive orthopedic trauma service; as trauma surgeons, we planned to provide acute care in the midst of an orthopedic disaster.

We expected many amputations. But we thought we could save limbs that were salvageable, particularly those of children. We recognized that in an underdeveloped country, a limb amputation may be a death sentence. It does not have to be so.

We thought our plan was a good one, but we soon learned we were incredibly naive. Disaster management in Haiti was nonexistent.

The difficulties in getting in -- despite the intelligence we had from people on the ground and Dr. Helfet's connections with Partners in Health and Bill and Hillary Clinton -- only hinted at the difficulties we would have once we arrived.

We started out Friday morning and got a slot to get into Port-au-Prince on Friday. That was canceled when we were on the runway and was rescheduled for the next day. We were diverted to the Dominican Republic and planned on arriving in Port-au-Prince on Saturday.

That Saturday morning slot also was canceled and postponed until the afternoon. The airport had one runway and hundreds of planes trying to land. But nobody was prioritizing the flights.

Once we finally landed, we were taken to the General Hospital in Port-au-Prince with our medical supplies. We had been told that this hospital was up and running with two functioning operating rooms.

Once we arrived, we saw a severely damaged hospital with no running water and only limited electrical power, supplied by a generator. Surgeries were being performed in the equivalent of a large storage closet, where amputations were performed with hacksaws.

This facility could not nearly accommodate our equipment nor our expertise to treat the volume of injuries we saw.

We quickly took our second option: Community Hospital of Haiti, about two miles away. There, we found about 750 patients lying on the floor. But the facility had running water, electricity and two functional operating rooms.

We found scores of patients with pus dripping out of open extremity fractures and crush injuries. Some wounds were already ridden with maggots.

About a third of these victims were children. The entire hospital smelled of infected, rotting limbs and death. Later on, we would judge our surgical progress by the diminishment of the stench.

In our naïveté, we didn't expect that the two anesthesia machines would not work; that there would be only one cautery available in the entire hospital to stop bleeding; that an operating room sterilizer fit only instruments the size of a cigar box; that there would be no sterile saline, no functioning fluoroscopy machine, no blood for transfusions, no ability to do lab work; and the only local staff was a ragtag group of voluntary health providers who, like us, had made it there on their own.

As we got up and running and organized the patients for surgery, we told our contacts in the United States what we needed. More supplies were loaded for a second trip. Those included a battery-operated pulse lavage, a huge supply of sterile saline and the soft goods we needed desperately in the operating room.

The plane landed as planned Sunday night, and the new equipment was loaded onto a truck. Then that truck, loaded with life-saving equipment, was hijacked somewhere between the airport and the hospital.

We had planned to run a marathon round-the-clock operation and leave at 11 p.m. Tuesday. We worked for 60-plus hours without stopping. The plane that would take us home would bring with it not only a new medical staff, but also equipment that was nonexistent in the hospital, or even the country.

These pieces of equipment, two of each, were urgently needed: portable anesthesiology machines; electrocautery machines to stop bleeding after amputations; portable monitors for the recovery room; autoclaves to sterilize equipment; and a lot of orthopedic equipment, which we were quickly using up. The other items were those that were on the previous flight and had been hijacked.

Officials at the Port-au-Prince airport canceled that plane's 6 a.m. Tuesday slot, and the plane never made it to us on time.

We had started to see daylight Monday night, having performed about 100 surgeries, which were mainly amputations, fixing broken limbs and soft tissue debridements. Many of the patients were children and babies.

But on Tuesday morning, a huge number of new patients arrived. The Haitians had heard we were trying to save limbs, and families were bringing their injured loved ones to us.

The hospital was forced to lock down, closing its gates to the angry and frustrated crowd outside. On Tuesday morning, we saw that many of the patients we had operated on were becoming septic and would require additional surgeries.

We finished operating at noon Tuesday, our last surgery assisting an obstetrician on a Caesarean section and helping to resuscitate a newborn who was not breathing.

We decided the situation was untenable. Our supplies were running out, our team was past exhaustion, safety was rapidly becoming a concern, and we had no firm plan to leave or resupply.

A hospital benefactor helped us get to the airport. First, Jamaican soldiers with M-16s escorted us out of the building as the crowd outside saw us abandoning the hospital. We made it to the airport on the back of a pickup, got onto the tarmac, hailed a commercial plane that had carried cargo to Haiti and was returning to Montreal, Canada, and had a private jet pick us up from there.

We were unprepared for what we saw in Haiti -- the vast amount of human devastation, the complete lack of medical infrastructure, the lack of support from the Haitian medical community, the lack of organization on the ground.

No one was in charge. We had the first hospital in the Port-au-Prince area with functioning operating rooms, yet no one came to the hospital to assess how we did it or offer help.

The fact that the military could not or would not protect the critical resupply medical equipment on Sunday, or allow the Tuesday flight to come in, is devastating and merits intense investigation.

There was no security at the hospital. We needed a much higher level of security with strong and clear support of the military from the very beginning.

The lack of support for our operation by the United States is shocking and embarrassing and shows how woefully unprepared we are for the realities of disasters. We came to understand that our isolated operation may work in a mission, but not in a disaster.

We first thought we would support those at the helm but soon realized we were almost the only early responders with the critical expertise and equipment to treat an orthopedic disaster such as this.

Still, nobody with a clear plan is in charge, and care is chaotic at best. Doctors are coming into the country with no plan of what they are going to do, and nobody directing them how to do it.

Surgeons who expect to show up and operate will be mistaken. Without a complement of support staff and supplies, they are of limited to no value.

We left feeling as if we abandoned these patients, the country and its people, and we feel terrible.

Our role back in New York is to expose the inadequacies of the system in the hopes of effecting change immediately. Patients who are alive and still have their arms and legs remain in jeopardy unless an urgent response is implemented.

The quickest and most efficient way to really help now and support the medical staff on the ground is to assess needs, provide equipment and personnel in necessary quantities, and bring them safely and expeditiously into the country and to the hospital units caring for patients.

Upon our departure, we witnessed pallets of Cheerios and dry goods sitting on the tarmac helping nobody. Yet our flight of critical medical equipment and personnel had been canceled, and the equipment that did get through was hijacked.

We implore an official organization to step up and take charge of the massive ongoing medical effort that will be necessary to care for the people of Haiti and their children. And to do it now.

The opinions expressed in this commentary are solely those of Drs. Dean Lorich, Soumitra Eachempati and David L. Helfet.

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Dispatch from Port-au-Prince--January 27, 2010

(Photo by John Carroll)

The following dispatch was written by Dr. Jean Pape. Dr. Pape has been medical director of a large HIV/Tuberculosis medical center in Port-au-Prince for many years. His medical complex was turned into a refugee center after the earthquake.

Even though this article is somewhat dated, it is still worth reading today.


Published at www.nejm.org January 27, 2010

The Earthquake in Haiti — Dispatch from Port-au-Prince

Jean William Pape, M.D., Warren D. Johnson, Jr., M.D., and Daniel W. Fitzgerald, M.D.

At 4:53 p.m. on Tuesday, January 12, an earthquake killed or gravely injured hundreds of thousands of people in Port-au-Prince, Haiti. Even more were left homeless. The devastation is incomprehensible.

Chaos followed, since the centers of law, order, and functioning society were destroyed or suffered severe losses. The Haitian national palace, government ministries, and police stations collapsed with major losses of life. The headquarters of the United Nations was in rubble, and hundreds of staff members were missing. Banks, churches, food stores, hospitals, hotels, schools, and communications capabilities were destroyed.

As a result, piles of bodies lay in the streets. The only useful places for providing medical care were empty spaces — parks and fields. A city in need of hundreds of trauma centers had two or three.

Four staff members from the organization with which we are associated, the Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (known as GHESKIO), died, several were severely injured, and many lost family members or were left homeless. A few GHESKIO staff members were able to reach our clinic in the center of Port-au-Prince on Wednesday, January 13. Several clinic buildings suffered severe damage and were not habitable. Others were damaged but usable.

The GHESKIO staff saw trauma patients and handed out antiretroviral drugs to patients with AIDS. As word spread that GHESKIO was "open," more patients came, many of them critically injured; refugees began camping on a field next to our clinic (see slide show).

By Thursday, January 14, we had 1000 refugees, many of them seriously injured. GHESKIO staff members provided chlorinated water to refugees, identified the most critically injured, bandaged them, and provided care. We did not have an operating room.

We communicated with the U.S. Embassy and offered GHESKIO as a site for a field hospital. We now had a functioning electric generator, vehicles, water, an open field, and functioning Internet access. Most important, we had our Haitian medical staff, who could triage patients, provide postoperative care, and translate.

For 3 days, we waited. The U.S. embassy pushed hard, but the airport was the bottleneck. Equipment, supplies, surgeons, and other medical personnel arrived from around the world but could not be coordinated, secured, and moved two miles to our clinic. The U.S. Army and a Department of Health and Human Services (DHHS) field hospital arrived on Sunday, and the hospital was operational on Monday, January 18.

By January 22, ten days after the earthquake, we are focused on three missions. First, we must provide food, water, sanitation, and security to thousands of earthquake refugees. We obtained food from relief agencies but hesitated to distribute it directly for fear of a riot. We therefore hired 40 women who work as street vendors. We provide them with cooking oil and food, which they prepare and distribute free of charge.

Our water comes from a well at GHESKIO. Running water is not available in Port-au-Prince. We initially chlorinated the water in barrels, but we have now obtained six filters.

We need latrines for the thousands of refugees. When we have shovels, picks, and wheelbarrows, we can hire people to dig the latrines. We are beginning to see patients arrive with severe diarrhea and typhoidlike fevers.

Security is now our biggest concern. Five thousand prisoners escaped from the National Penitentiary, which was a short distance from our clinic. They have infiltrated our refugee camp. They are armed and organizing. The U.S. Army protects the DHHS field hospital but is not responsible for the refugee camp or the GHESKIO clinic. The walls around our facility collapsed, and our clinics are open to the streets. There is no electricity in the city, and there are no lights at night. Our clinic staff and the refugees are frightened. It is increasingly difficult and dangerous to distribute food and water. More security forces are needed. A barbed-wire perimeter and solar-powered street lights would make the camp and clinic safer.

The U.S. field hospital initially hired its own Haitian translators, with good English as the primary requirement. Many of the new hires were deportees from U.S. prisons who had just escaped from the penitentiary. We removed them and got Haitian students to volunteer as translators.

Our second mission is to support the field hospital. More than 95% of the medical problems we saw in the first week were trauma-related. The number and severity of fractures are unbelievable. We are now starting to see gunshot wounds. Our DHHS field hospital has 70 U.S. volunteer doctors and nurses providing emergency and surgical care. They are saving hundreds of lives.

We are supporting the American DHHS surgeons. Haitian doctors are triaging in the refugee camp and providing postoperative care. We have obtained a large tent for 100 people from the Swiss Red Cross and are using it as a postoperative center. We are now using the GHESKIO x-ray machine, since the mobile hospital did not have one. We are using our private vehicles as ambulances.

Diesel fuel for vehicles and generators is scarce. The U.S. field hospital ran out of fuel, and we provided them with diesel. We just received a shipment of 2000 gallons from our friends at Partners in Health and the Clinton Foundation, and we were able to get another 1000 gallons from a local supplier.

Coordination between the supply chain and patients is urgent. At present, we do not know the capacity of the different hospitals. A patient may be painstakingly taken to a hospital only to find out that the hospital cannot offer the services needed, either because they are not available or because the hospital is overcrowded. In some cases, it is the availability of surgical supplies, such as external fixators, that can limit services; none are available right now at either the GHESKIO clinic or the University Hospital.

We are working with the minister of health to develop a comprehensive hospital-capacity inventory and information system by dividing the city into regions. We want hospitals to indicate their capacity and the availability of services. Since this information is likely to change every 2 to 3 hours, each hospital should provide hourly updates. This information should be centralized at the Ministry of Health and given to all radio stations to inform the population where to go for care.

Our third mission is to continue providing medications for our 7000 patients with AIDS and tuberculosis. Before the earthquake, we developed an emergency plan for our patients in the event of a political upheaval or hurricane. Patients have been routinely provided with an extra 2-week supply of important drugs. Patients were counseled to come to the clinic if possible or to go to one of four predesignated GHESKIO drug-distribution centers in the city. This plan was put into effect the day after the earthquake and is working.

A GHESKIO clinic team is providing HIV and tuberculosis care. Staff members carpool because fuel is limited. Each car owner receives 5 gallons of diesel. An emergency shipment of drugs was brought to our clinic 1 week after the earthquake by a team from PEPFAR (the President's Emergency Plan for AIDS Relief). They continued to unload medications during a severe aftershock. We are working with drug distributors in the Dominican Republic to organize a truck delivery of large quantities of medication.

We try to contact patients by cell phone, but most patients do not have electricity to charge their batteries. One of our doctors went on a popular radio station to announce that GHESKIO is open and also provided the names of hospitals in the countryside that can provide drugs. About 65% of our patients are coming to the clinic, although public transportation is very limited. Another 15% receive their medications at four designated delivery sites. Approximately 20% of patients are unaccounted for.


Financial and other disclosures provided by the authors are available at NEJM.org.


Source Information

From the GHESKIO Center (J.W.P.) and the Center for Global Health, Weill Cornell Medical College, Haiti (J.W.P., W.D.J.) and New York (D.W.F.).