Haiti: Are We Learning Anything?

Methodical versus agile…resources guaranteed versus resources hoped for…government versus private. Sound like a competition? It shouldn’t be.

Dr. Christopher Born, Chief of Orthopedic Trauma at Brown University, went to Haiti on an official U.S. government mission that was self sufficient and protected by the Army’s 82^nd Airborne Division. Dr. David Helfet, Director of the Orthopaedic Trauma Service at both Hospital for Special Surgery (HSS) and New York-Presbyterian Hospital, moved by the disaster, organized his own team, secured whatever resources he could and struck out on his own mission. Their experiences, vastly different, shed light on the need to find a middle ground between the two extremes. Why? Because unlike many orthopedic situations, disasters such as the Haiti earthquake can mean swift death for those left untreated.

Aid With Government Support

Dr. Born: “There are three International Medical Surgical Response Teams (IMSuRT), one in Seattle, one in Miami, and another in Boston—all of which are under the auspices of HHS/National Medical Disaster System. When the volunteer team is activated, each member becomes a federal employee. After that, things start clicking according to a well-established plan.”

IMSuRT field hospital patients being loaded for medivac to USNS Comfort

So the question is, “How do you plan without plodding?” Dr. Born says, “The benefits of being part of the IMSuRT team were many—no transportation glitches, full complement of materials, etc. The downside was that, as a government entity, we were at the behest of the decision making chain operating above us. This meant that we could not leap into action upon our arrival in Haiti…in fact, it was three days before we could begin operating. This is obviously in great contrast to the nimbleness of non governmental organizations (NGOs) or private groups that can do whatever they deem necessary.”

Dr. Born, Chair of the Mass Casualty Response Committee for the Orthopaedic Trauma Association (OTA), seeks common ground between the two approaches.

There should be a way for the government and non governmental entities to work together harmoniously. While the latter parties often managed to get themselves to Haiti quickly and were obviously well intentioned, they may have been naïve in their expectations. In fairness, however, I don’t think anyone knew what they were getting into.

A glaring issue that could have been a distraction to the medical work at hand was security. “We were alerted early on that the security situation was questionable, ” says Dr. Born, “and in fact were unable to leave the U.S. Embassy compound until an advance team could identify a place to set up a hospital and establish provisions for security. They settled on the courtyard of Gheskio University, and we had the field hospital up in eight hours. By 9am there were several hundred people lined up for treatment, with an entire tent city just outside the university. We had set up gates in order to handle things in an orderly fashion…then the triage team just went down the line.”

The enormity of the situation required extreme focus. There was no time or resources for A to Z care. Dr. Born: “There were numerous open fractures and crush wounds, most of which were several days old and festering. After amputations, debridements, splinting, casting, and external fixation, it is unfortunate, but there will be little follow up care for patients. The best we could do was to temporize, debride, and keep the wounds clean. Definitive surgery such as IM nails, plates, etc., would have to be done at larger centers when they are functioning. Several amputations were required secondary to the dirty open wounds and potential for sepsis. The complex injuries have little chance to undergo the reconstructive procedures required to treat them properly. Thus, we tried to deliver the ‘minimal standard of care’ under very austere circumstances.”

Putting a fine point on it, Dr. Born states, “The medical legacy of this disaster is the musculoskeletal injury. There were so many amputations for injuries that under normal circumstances would have been treated differently. Thus, after the dust settles, there will be a cross generational component of the population who have lost limbs. This is a particular economic issue in Haiti because most people earn a living through manual labor.”

Preparing for Disaster

As Dr. Born made his way through the trauma of Haiti, one resounding message ran through his head…prepare. “Everything comes down to planning and organization. While you cannot be ready for every eventuality, you are best off with some kind of preexisting plan for which you have drilled. And in any disaster you must have a chain of command with the appropriate person in charge. There should be clear delineations between who will be delivering the care, who will be handling logistics, etc. You don’t want to send surgeons out foraging for water.”

“The U.S. is in great need of a system that includes precredentialed individuals to respond quickly in disasters. But it is difficult to move through the government bureaucracy to develop a database of qualified people. Finding government entities and/or individuals to work with who will sidestep politics is a problem.”

“Having experienced logistics people on board is invaluable, ” adds Dr. Born. “The people handling this for us were EMS personnel and firefighters, and they seemed to be able to troubleshoot anything. The generator went down, and they fixed it; we ran out of oxygen, and they figured out how to get it locally and brought it into our system.”

Even someone experienced with disaster response can be jolted.

I was unprepared for the depth and breadth of the devastation and sheer numbers of people. The death toll is likely around 200, 000, with approximately 250, 000 injuries. That level of destruction puts it at the top of all earthquakes in the last 70 to 80 years. Think about this…it was not just a small town that was destroyed…it was the capital. The devastation to the infrastructure is incalculable.

“You block all of this out while you are working, though, and think about it later. When we arrived back in the U.S., we were debriefed by the U.S. Public Health Service. They were clear that help was available if we had any medical or psychological issues.”

Lives will be saved, says Dr. Born, when all parties are willing to pull together. “We need to continue to develop an integrated disaster response system that includes the government, NGOs and private citizens who have valuable skills that can be rapidly mobilized in a coordinated fashion. For disasters involving large numbers of musculoskeletal injuries, industry partners must also be involved. Finally, integrating all of this with the military for transportation, security and logistical support is imperative.”

Dr. David Helfet, whose team was on the ground in Haiti within four days of the earthquake, couldn’t agree more. “While the U.S. has been remarkable in its response, the medical relief has been tremendously disorganized. If we have another devastating hurricane or earthquake, there is no organized mechanism to rely on. We have a very clear, tailored response to a nuclear issue…why not one for natural disasters or terrorism?”

Offering Aid With Private Funds

The earthquake struck Tuesday evening—by Wednesday morning Dr. Helfet had secured a commitment of staff and supplies from both HSS and New York Hospital. “I also contacted the Chair and CEO of Synthes, who said, ‘We’ll give you whatever you need.’ They generously provided their company jet to get all 12 of us to Haiti. Despite contacting one of President Clinton’s advisors about a landing slot, we had trouble. The Thursday slot was cancelled; we got one for Friday, but were denied access by Haitian air control…there was no one in charge.”

Landing in the Dominican Republic Friday, Dr. Helfet and his team eventually flew into Port au Prince Saturday. “After circling the airport for three hours, we landed and were met by Partners in Health, who brought us six SUVs and an armed guard. The first facility we went to was the main public hospital of Haiti (in Port au Prince). There were approximately 1, 000 patients at the hospital, with about 1, 000 bodies lying behind the hospital. Along with the evidence of decay and death, the hospital had no electricity or water, while the OR consisted of a plywood table in a storeroom. I quickly decided that this was not going to work.”

“We located a community hospital with a similar amount of patients, which was in better shape—they had two ORs, electricity, and occasional water. (Saline was rationed—normally we would use nine 9 liters for lavage, but we cut that to one liter per patient).”

These doctors had to make quick, tough decisions. Dr. Helfet: “Working 20 hours a day for four days, we did over 100 cases. Along the way we were essentially playing God in deciding who received treatment when. The team agreed that children would be treated first. The following day, a plane came with more supplies, but somehow, between the airport and our hospital our supplies disappeared. There was no security, we began running out of supplies, and there were no Haitian police in sight. Patients were angry because we could not help them, and it was clear that the situation was deteriorating. The team left on a Canadian charter plane, depressed, and knowing that we had left the job unfinished.”

In such a crisis, says Dr. Helfet, you need a General Patton. “I traveled to Istanbul in 1999 to help with the earthquake relief effort. Two days into that disaster they got over the ‘government versus military’ issue, declared a national disaster, and gave the military total control. We should take a lesson from that…any disaster plan should be under the control of the military with a top notch leader in charge.”

Recalling the images from Haiti, Dr. Helfet notes, “No one had control of the streets, which of course is going to lead to supply issues. If the Haitian government had temporarily relinquished sovereignty in exchange for all the resources it was receiving, things could have gone much more smoothly.”

Dr. Helfet, who has put his mission on hold until the team can be part of an umbrella organization, states,

You just can’t go in alone. It’s inefficient, distracts from the work, and is potentially dangerous. The government needs to spearhead an effort to create an organized central command dedicated to relief. What, after all, did we learn from Katrina?