Reports of Gangrene and Sepsis... And The Stark Realities of Response in Haiti

We have seen multiple reports of gangrene and sepsis over the past several days.  Unfortunately yet another expected infectious disease issue.

The below narrative by a New York City orthopedic surgeon provides, in graphic detail, the infectious disease challenges that have been observed in the Haiti response theater.  Here we have decided to protect the identity of the team involved.  They were gracious to provide a blunt testimony of their experiences.

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

• 2 orthopaedic trauma surgeons
• 3 orthopaedic trauma fellows
• 2 highly skilled anesthiologists
• 1 general surgery trauma surgeon
• 2 scrub techs
• 1 trauma nurse practitioner to do triage
• 2 OR nurses

 
Our equipment including a huge amount of anesthetic medications and equipment, ability to construct 150 external fixations both small and large, OR equipment including scalpels etc, OR soft goods, splint material, OR prep material.
 
We also had a plan of physician and equipment replacemnt that was dynamic where within 24hrs we could bring in what was necessary on private jet.
 
We thought the plan was a good one.
 
We were incredibly naïve.
 
Disaster management on the ground was nonexistent.  The difficulties in getting in despite the intelligence we had from people on the ground and high political connections with [XXXX] as well as [YYYYY] only portended the difficulties we would have once we arrived.
 
We started out Friday morning, got a slot to get in Friday that was eventually cancelled when we were on the runway to be rescheduled the next day.  We diverted to the DR and planned on arriving in PAP Saturday.
 
Once on the ground the hospital we had intelligence that was up and running with 2 OR's General Hospital was included severely in the earthquake and not capable of running functioning OR's as there was no running water and only a limited electrical supply on generator.
 
We quickly took our second option: Community Hospital of Haiti.  We found approx 750 patients in the hospital upon our initial evaluation, the hospital had running water, electricity and 2 functional OR's.  [In] our naivette [we] did not expect that the 2 anesthesia machines would not work, there would be 1 cautery for the hospital, autoclave that fit instruments the size of a cigar box, no sterile saline, no functioning fluoro and no local staff only a ragtag group of voluntary health providers who like us had made it there on there own.
 
To summarize we had no clue the medical infrastructure of the country was so poor.
 
As we got up and running in the OR and organized the patients for surgery we communicated our new needs back to [ZZZZ} and more supplies were loaded for a second trip - these included battery operated pulse lavage, a huge supply of saline, soft goods in the OR.  This plane landed as planned Sunday pm, equipment was loaded on a truck and subsequently hijacked between the airport and the hospital.
 
At the hospital we had zero security despite promises form to provide that to us.
 
Our philosophy was to work like this was a marathon run the OR's around the clock with the idea that we would have a defined extraction time of 11pm Tues.  The plane that extracted us would come in with a new medical staff compliment to replace us. Equipment included urgent things to maximize issues that were nonexistent in the hospital that would enable us to provide better and more efficient care:
 

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

 
That plane's slot was cancelled by the military at 6am Tues.

We also previously had seen daylight in the remaining patients Monday night having completed approximately 100 surgeries.  However on Tues morning we found a huge number of new patients.  The hospital was forced to undergo lock-down closing its gates to the outside and outside crowd becoming angry.
 
We also noted Tues morning that many of the patients we were operating on were becoming septic.
 We finished operating at noon Tues, the last surgery our group assisting an obstetrician on a Caesarian and resuscitating a baby that was not breathing.
 
We decided as a group the situation for us at the hospital was untenable supplies were running out, team was exhausted, safety a huge concern, and no extraction plan with resupply.  We decided to make our way to airport through the help of a hospital benefactor.  Jamaican soldiers with M-16s were necessary to escort us out with our luggage as the crowd outside saw us abandoning the hospital.
 
We made it to airport on back of a pickup track, got onto the tarmac, hailed a commercial plane that carried cargo to Montreal and had private jet pick us up there.
 
 The issues we were unprepared for and witnessed were:

1. The amount of human devastation
2. The complete lack of a medical infrastructure in the country
   
3. The lack of support of the Haitian medical community
   
4. The complete lack of any organization on the ground
5. Lack of any security at all at the hospital

No one was in charge, we had the first functional up and running hospital in the PAP area yet no one and I mean NO ONE came to the hospital to assess what we were doing, what we were capable of doing and what we would need, to be more efficient.

 
I would take away that disasters like this need organization on a much higher level than we had with the clear involvement and approval of the military from the beginning.
 
Currently there is no one obviously running the show and care is in chaotic at best.  MD's are coming in country with no plan of what the are going to do.  Surgeons that expect to just show up and operate are delusional as to what there role would be as without a complement of support staff and supplies they would be of limited or no value...
 

Comments

[Alanna_shaikh]

Thanks so much for sharing this story - it's important, and other people can learn from it.

[Daveove]

This is a great story, and I hope that it brings some perspective for people who have good intentions but might not fully understand the conditions. Even on the best day, the majority of the developing world wouldn't have the supplies, infrastructure, or resources to deal with normal medical emergencies, let alone this type of aftermath.

[David Courter]

These medical professionals were overwhelmed with the need to help and they determined that the skills and equipment that they had could be put to good use assisting the people in Haiti. They did what they thought best, and they did it well. As a result they made a difference in many lives.

The events as laid out are disturbing and frightening. Hopefully the lessons these folks suffered through will not be lost on others. Then the next time even more people can be assisted and saved.

The most efficient and effective disaster management practices are not intuitive. Many well meaning people get extremely frustrated with what appears to be a lack of organization and an excruciatingly slow response. From personal experience I know it is incredibly frustrating for medical professionals to sit and do nothing as more people die knowing if you were on the ground you could be saving lives, BUT, we can not just jump in on our own to help.

We in the disaster response community applaud the intentions and efforts of people who are willing to step forward and help out. We invite you to join us in helping. We have a huge job that continues to grow. What we would like the most is the opportunity to share the knowledge you and we both have and to train as a team so in the future we can utilize our skills and resources to their greatest potential. Contact your local NDMS DMAT team, a group of physicians, nurses and other allied health professionals all dedicated to help those in need as a result of disasters.

[David Courter]

Links for info on NDMS and DMAT opportunities.

Who we are and what we are about:
http://www.hhs.gov/aspr/opeo/ndms/teams/dmat.html

How to get involved:
http://www.hhs.gov/aspr/opeo/ndms/join/index.html

[James M. Wilson V, MD]

These are very good comments. An old friend of mine, an experienced emergency physician who has spent several years on missions to Haiti, had the following observation:

"Very interesting just how naive these groups are. The hospital I work with in Jeremie Haiti has no oxygen, no electricity, no pharmacy. And that was before the earthquake. No lab, no blood products. You could come in with the most obvious case of appendicitis ever, but until you go to the various pharmacies and buy the surgeon's gloves and suture, ... See Morethe IV tubing and fluids and antibiotics, there will be no surgery....and don't forget the diesel to run the generator for the anesthesia machine and lights. I continue to be amazed appalled by the reaction of American medical providers who obviously have no idea what 3rd world conditions are."

[Catherine Mitchell]

Not only are we naive about what 3rd world conditions are really like across the board not just medically, we are naive in our thinking that we are immune from living in 3rd world conditions ourselves.

I read this report and I have a visceral response to the description of pain and suffering and the heroic efforts of those called to give care.

The question always on my mind, are we are allowing a preparedness window to close on us right here and now? Can one truly prepare for disasters of such scale as the utter devastation that happened in Haiti this time?

Thinking that man's inhumanity to man is also a threat and something that could happen anywhere at any time how should we best prepare?

Biosurveillance is a help and I applaud you for what you do by allowing a glimpse into the reality of disaster situations+ in order that we may gird ourselves.

I do think that would behoove us to think long and hard about what would happen if a major disaster of widespread scope hit us at home. More than a few cities hit at once and our response would become more 3rd world-like.

Just trying to think ahead of the curve a bit...

sorry if I am off on a tangent.