Tuesday, January 26, 2010

Best intentions

So, the following is something I received in an email today. It's a forwarded email from a physician who went down to Haiti to provide care. I know I thought of going. Yes, I'm a shrink, but I am an MD, which means I can provide basic medical care. I used to be a surgeon, so while I couldn't necessarily operate on my own, I'm an excellent first assist. I pick things up quickly, so can provide a versatile range of services. Not the least of which is, you know, I'm a shrink. Ultimately, though, I concluded I had neither the flexibility of schedule nor the funds to do so.

What I wasn't expecting to hear from those on the front line was how unbelievably primitive the medical conditions were before the quake. I....find this unfathomable, that we, the major powers of the world, allow this to happen in less developed nations. This email, I think, does an excellent job of pointing out why the "a little here, a little there" approach to aid to Haiti pre-earthquake just doesn't cut it in any sort of humanitarian sense. What little I personally can do about this, I think, is give them a venue to disseminate this message.
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.

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

Our equipment including a huge amount of anesth medications and equipment, ability to construct 150 ex fix both small and large, OR equipment including scalpels etc, OR soft goods, splint material, OR prep material. We also had a plan of physician and equipment replacement that was dynamic where w/i 24hrs we could bring in what was necessary on the Synthes private jet.

We thought the plan was a good one.

We were incredibly naïve.

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

We started out friday morning, got a slot to get in friday that was eventually canceled when we were on the runway to be rescheduled the next day.  We diverted to the DR and planned on arriving in POP saturday. Once on the ground we had intelligence that
the hospital was up and running with 2 OR's General Hospital was included severely in the earthquake and not capable of running functioning OR's as there was no running water and only a limited electrical supply on generator.

We quickly took our second option

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

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

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

Our philosophy was to work like this was a marathon: run the OR's around the clock with the idea that we would have a defined extraction time of 11pm tues.  The plane that extracted us would come in with a new medical staff compliment to replace us. Equipment included urgent things to maximize issues that were nonexistent in the hospital that would enable us to provide better and more efficient care:
2 portable anesth machines
2 portable monitors for the pacu
Replacement exfix
Things that didn't arive 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 approx 100 surgeries.  However on tues morning we found a huge # of new patients.  The hospital was forced to undergo lockdown closing its gates to the outside and outside crowd becoming angry. We also noted tues morning that many of the patients we were operating on were becoming septic.
We finished operating at noon tues, the last surgery our group assisting an obstetrician on a caesarian and resuscitating a baby that was not breathing.

We decided as a group the situation for us at the hospital was untenable supplies were running out, team was exhauted, safety a huge concern, and no extraction plan with resupply.  We decided to make our way to airport thru the help of a hospital benefactor.  Jamaican soldiers with M-16 were necessary to escort us out with our luggage as the crowd outside saw us abandoning the hospital. We made it to airport on back of a pickup track, got onto the tarmac, hailed a commercial plane that carried cargo to montreal and had private jet pick us up there.

The issues we were unprepared for and witnessed were
1.  The amount of human devastation
2.  The complete lack of a medical infrastructure in the country
3.  The lack of support of the haitian medical community
4.  The complete lack of any organization on the ground.  No one was in charge, we had the first functional up and running hospital in the POP 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.  The fact that the military could not or would not protect the resupply equipment on sunday or let the tues flight come in says it all.
5.  Lack of any security at all at the hospital

I would take away that disasters like this need organization on a much higher level than we had with the clear involvement and approval of the military from the beginning. Currently there is 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 their role would be as without a complement of support staff and supplies they would be of limited or no value.

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

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

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

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