K. Gage Parr, M.D.
My Trip to Haiti
January 23-29, 2010
Like most people, I was saddened when I heard the news and saw the pictures of the devastation in Haiti following the January earthquake. However, it was a remote tragedy in a country that I had never visited and had no direct contact with, so I sent some money to the American Red Cross and went along with my life. Then a vascular/general surgeon in my hospital, Moji Gashti, who travels to Haiti yearly, put out a call for anesthesia providers to travel with him to Hopital Sacre Coeur in Milot, Haiti. I decided this was my chance to provide more than money to people in need and signed up to go to Haiti from Jan 23rd to Jan 29th.
Having never done a medical mission before, I had no idea what to expect. I knew that the hospital where we would be working was in the northern part of the country, which had been minimally affected by the earthquake and was receiving patients via airlift from Port au Prince (PAP). I also knew that my skills as a cardiac anesthesiologist would probably not be needed. So I went, ready for anything and ready to do anything I could to help.
My group arrived in Cap Hatien, Haiti on a donated private jet from Fort Lauderdale midday on Saturday the 23rd. The group included myself, Dr Gashti, a nurse anesthetist from my hospital, a surgical intern from my hospital, an anesthesiologist from Florida, Dr. Dennis McCarthy, and two operating room (OR) nurses from New Jersey. After loading the massive quantity of supplies that we had brought with us from the states and ourselves into and onto our Land Cruiser, we took off on a very bumpy hour drive to Milot. We arrived at the Hospital, unloaded our gear and were immediately taken on a tour of the hospital.
What had once been a 75 bed facility when jam packed, had been quickly increased to 300 beds. One school across the street from the hospital building had been turned into the Emergency Department (ED), which was quickly dubbed the USS Discomfort, and another was now the ‘new hospital’ where most of the inpatients were housed. These schools were basic cinderblock and concrete structures with one or two electrical outlets per room. There was no air conditioning or windows, light, bugs, dirt, etc. came in through the open doorway and holes in the cinderblock. Sheets had been hung over the walls to provide some privacy to the patients who were housed in camp cots or mattresses on the floor. In the ED, tarps had been raised between the building and trees to provide shade to the triage area. In addition laundry and trash filled the open spaces.
The ‘old hospital’ or original hospital building had been completely transformed. The lobby of the hospital, where patients had once waited for clinic appointments was now pre-op holding. Patients waited on military litters or ancient stretchers for care in the operating rooms. The former PACU was now a combination of PACU and ICU, the upstairs ward still housed patients and the pediatrics ward was packed with children. Many kids had been separated from or had lost their parents during the earthquake and were being taken care of by the locals from Milot. There were three operating rooms with anesthesia machines and air conditioning, but only one had a working ventilator. One of the operating rooms (OR 3) had been a labor room and the room was tiny, poorly lit and filled with flies. There were also three procedure rooms. Miraculously, a day or two before monitors for all of the OR’s, procedure rooms, the PACU/ICU, ED and some of the wards arrived. This allowed us to have full monitoring capabilities including pulse ox and capnography. It made our job, much, much easier. Oxygen supplies were more problematic; all oxygen came from H tanks in the rooms, which were refilled from a truck once a day. There were tanks for all of the OR’s, but often there were no full tanks for the procedure rooms, which left us with the option of doing local only cases in these rooms or cases without supplemental oxygen.
After the quick tour we were put to work. The anesthesia team that was there when we arrived consisted of two anesthesiologists from New Jersey and two CRNA’s from Missouri. They had arrived shortly after the earthquake and had relieved one anesthesiologist who happened to be there when the earthquake hit. This anesthesiologist had apparently been running two rooms 24/7 using the Haitian CRNA’s that were exhausted and in over their heads. The team we relieved had been working hard, but as the acute casualties had diminished and less acute cases such as long bone fractures and wound debriedments had increased, days were shortened to maintain the health and sanity of all of the health care workers, especially the Haitian nurses.
My first afternoon in the OR was spent taking care of patients with leg fractures. As there was only one working ventilator, regional anesthesia was anesthetic of choice. I dusted off my regional skills and spinal blocked the patients, using the local anesthetics we had even if they were not ideal for the block I was trying to perform. I have to say that in general the Haitians were very stoic and very appreciative of what we were doing for them. Most lay on the table with little or no sedation, it was only when the block began to wear off that I heard a peep from them. When this happened, I would convert to a general with an LMA and tell the surgeons to hurry up. The surgeons were also struggling with limited and mismatched equipment, no fluoroscopy and a language barrier with the Haitian nurses who were scrubbed. The surgeons were from all over the US and working with anesthesia providers and circulating nurses who were also from all over the US. It created a bit of confusion, but we worked through it, because there were really no options. You could not be high maintenance or a prima donna in that environment, because you wouldn’t survive ten minutes. When we were done with a case the patients were extremely appreciative, some had been waiting for surgery for days to weeks and to finally get care was a huge relief.
While the cases were going on, I tried to sort through the supplies that had been brought in by the anesthesia providers that had arrived since the earthquake. The hospital had a surprising number of supplies. Propofol, local anesthetics, anesthetic gasses, narcotics, benzodiazepines, IV catheters and tubing, LMA’s, ET Tubes, etc. But because it had all arrived in a short period of time and people had brought what they thought would be needed, it was incredibly unorganized. I and the other providers, ran from room to room asking the provider in that room if they had this or that. In general we had what we needed and smiled through the chaos.
The first night that we were there they had a young girl with tetanus brought from the wards to the OR. The tetanus was from a wound she had suffered in the quake. The team in the OR that evening treated and resuscitated her, bringing her back from a full cardiac arrest. For a while it looked like a huge save, but she succumbed to the disease during helicopter transfer to the USNS Comfort. It was a stark reminder that no matter how much the staff at the hospital tried to save these patients and how much expertise they brought, there were things that couldn’t be overcome.
That evening I went back to the compound where the visiting hospital staff was housed and enjoyed an ice-cold beverage. As the hospital was not in Port au Prince, we had ample food, shelter and running water. The compound was full to bursting with visiting staff and I wound up sleeping in the living room of a convent on a camp cot. It was like being back at summer camp, with roosters to wake you up early instead of a PA system.
There was a full OR schedule on Sunday. I was again assigned mostly orthopedic patients and spent the day with leg fracture patients and once again sorting through a mountain of supplies. After feeling overwhelmed the first day, I began to get my feet under myself. I reduced my pre-op interview to: have you eaten today, do you have any major medical problems or any allergies to medications? (Most had never been to the doctor so the answer to the last two questions was generally no.) As an OR staff, we worked through at least thirty cases during that twelve-hour day.
There was a patient tracking system of sorts. The surgeons posted cases for the next day on slips of paper that were taped to the wall of the corridor outside the OR’s. In the evening two or three anesthesiologists went through these slips and tried to sort them by acuity, general/regional cases that required an OR vs. cases that could be done in the procedure rooms and which cases should go early in the day (pediatric cases or long cases). The OR translator, Pierre, then got a team of transporters and brought over 15-20 patients from the ‘new hospital’ to pre-op holding. These patients spent the night in pre-op holding with strict instructions not to eat anything after midnight. Pierre also told all of the patients for the next day not to eat after midnight. Despite this, as a team, we probably had to cancel about a fifth of the patients we brought to the OR after lunch because they had eaten. The transporters were young men from the area who volunteered to transport patients. We had no wheelchairs and stretchers were not useful because the patients had to come from the ‘new hospital’ over a dirt path and an unpaved road. Therefore they carried the patients on litters back and forth. The teams of transporters all had matching shirts, one group had t-shirts saying Chicago Bears 2006 Super Bowl Champions, which of course lost to the Colts that year.
Most of the patients came to the OR with IV’s and empty bottles of IV fluid. The patients would have IV’s started in the ED and then once the bottle was empty a new one was not started. This resulted in a great number of dehydrated patients. I and the other members of the anesthesia team, were generally able to get these IV’s going again, but one learned quickly that ‘pique, pique’ meant that this is going to hurt in Haitian Creole. I also learned quickly that the availability of narcotics in the ‘new hospital’, the willingness of the patients to ask for pain medicine and the Haitian nurses to give it was variable. For this reason I tried to load patients up with morphine before they went to the PACU and back to the ‘new hospital’ in order to provide them with some pain relief.
I spent Monday providing anesthesia in one of the procedure rooms. These rooms were supposed to be for sedation cases, but we were basically doing ‘general anesthetics’ with propofol and reused nasal canulae on everyone. These were not all small cases. They ran from cast changes in children, to a woman who had a large groin laceration that required debriedment and packing. As PACU space was limited, those beds were reserved those spaces for people who had had regional or general anesthesia. For this reason the plan was to discharge people from the procedure rooms directly back to the ‘new hospital’. It was tricky to try to give these patients enough sedation and narcotics to keep them comfortable, while keeping them awake enough to maintain their airway and saturations without supplemental oxygen. I took the oxygen off of the patients and stopped sedating them while the dressings were going on, if the patient maintained their saturations during this five to ten minute period they were good to go back across the street, sometimes they even walked. Two cases that stick with me from that day are a four-year old boy who had had a traumatic amputation of his right arm above the elbow and a man with a puncture wound in his hand. He lived in New York City and was visiting relatives in Port au Prince with his wife and some of his kids. His wife and kids were killed in the quake and he had more kids back in New York. I don’t know if they knew if he was alive of dead. It’s stories like that which made me somewhat glad I can’t speak French or Haitian Creole.
After two and a half days working in the OR I was considered to be an expert and as a result got to coordinate the OR on Tuesday. More reinforcements had come so the hospital was well staffed with anesthesia providers at this point. My major goal was to keep the cases moving and make sure that everyone had what they needed to do their cases. Cases were done whenever possible and there were only two real reasons for cancellation. One was the patient had eaten and the second was if they couldn’t be found. There were a surprising number of patients who went missing, some had expired before they got to surgery but some just disappeared. Pierre, our translator, worked hard to find every patient, but many were just gone.
On Tuesday I had my first experience with the hospital laboratory. We were lucky that Hopital Sacre Coeur has the only accredited hospital lab in Haiti. This lab, which was the result of one very dedicated nun, was able to run complete blood counts (CBC’s), basic metabolic profiles (BMP’s) and had a blood bank that could type and cross units of whole blood. We had one patient that day who needed an ORIF of a femur in one leg and of a tib-fib fracture in the other leg. I tried to order an early morning CBC the night before, it didn’t happen, but I drew it that morning and ran the sample over to the laboratory for the CBC and for type and cross. There were no stickers, no bar-codes, no order forms, just my handwriting on the test tube, a verbal order and handwritten results in French that came back to us in about 45 minutes. After a while the CRNA in that room asked for a unit of blood and I ran over to the lab to get it. Imagine my surprise when they asked for a requisition slip. Up until this point I had seen very little paperwork. There was a limited anesthetic record, which had an abbreviated pre-op in French and an anesthetic record in English. The surgeons were writing notes in English and the Haitian staff notes were in French in a chart that was in a manila folder. There were medication orders for the ‘new hospital’, but I had never had to order anything, if you needed it you went and got it. It was an odd moment of normalcy in what was not a normal place.
That evening the anesthesia team took care of a patient, who was not an earthquake victim, but wound up being one of the most acute of my stay. He was a 52 year-old man with an incarcerated hernia who had been sitting upstairs in the ‘old hospital’ for a number of days. A nasogastric (NG) tube had been placed and he was being followed by one of the Haitian general surgeons, who had asked the vascular/general to take a look. He was brought to the OR 1 that evening and his hernia was reduced without incident under general endotrachial anesthesia using the only anesthesia machine with a functioning ventilator. Despite copious NG tube output, he was extubated at the end of the case because there were no ICU ventilators. Unfortunately he aspirated after extubation and had to be re-intubated. The anesthesiologists then took shifts monitoring the patient. It was thought that he would not make it thorough the night, but he did and developed what we presumed to be ARDS. There was no ability to get a portable X-ray, no broncoscopes or Swan Gans Catheters, so all that could be done was suction the patient, watch and wait. The anesthesia machine he was on was burning through a great deal of oxygen in H tanks to generate enough pressure to maintain the patient’s oxygen saturation. On the evening after the patient’s surgery we had six anesthesiologists in the OR trying to figure out how to run the machines off of the H-tanks and or find another solution. We were not successful. There was an attempt to get the patient to the USNS Comfort, but the ship was full and we were unsure that a transport ventilator would be able to oxygenate him for the trip.
The next day, with no improvement on the part of patient, the case became a complicated medical ethics question. The patient was apparently one of the first ones in Haiti if not the first one in Haiti to be on prolonged mechanical ventilation. There were many issues: the patient was using valuable medical resources that were needed for other patients and it was unclear how long he would need ventilation. There was no real frame of reference for the Haitians in dealing with this type of ICU existence, and we were in a Catholic hospital. The patient was already at the average life expectancy for a Haitian man. After a great deal of discussion with the Haitian doctor who was chief of staff for the hospital, the patient’s family, the head of the American group of doctors, the head American nurse, an American Catholic priest at the hospital and consultation with Catholic Board back in the U.S., it was decided to withdraw support from the patient. Apparently, the Catholic Church has definitions of extra-ordinary measures that vary from country to country. A case such as this in the U.S. would not be considered using extra-ordinary measures, but in Haiti it is. Therefore support could be ethically withdrawn in the eyes of the church. There was also the consideration that even if he had survived, he may have had long-term pulmonary damage, which would not be treatable in Haiti. There is no such thing as home oxygen in Haiti. It was a sad reminder that what is easily treatable in the U.S., is not in Haiti.
The remainder of my time in Haiti was spent much as I have described above. U.S. Navy helicopters arrived every day bringing new patients and others arrived via car having taken the long bumpy ride from Port au Prince. With the arrival of more anesthesia providers, I was able to take a morning off and visit a nearby ruined fort. The Haitians built the Citidelle, after their revolution in the early 19th century as a last line of defense against French re-invasion. It is situated high atop a mountain and is a remarkable feat of architecture. It has an unbelievable amount of late 18th and early 19th century cannons and ammunition. Thousands of Haitians died building it. In any other country it would be a major tourist destination with tour buses, guides, souvenir shops and guide pamphlets. In Haiti, I paid $20 to tour it and $5 for a horse ride to the top of the mountain. The area around The Citidelle was extremely poor, and houses were made of sticks and mud with corrugated tin roofs. It was easy to see how Haiti is the poorest country in the Western Hemisphere.
Since my departure from Haiti, substantial advances have been made at Hospital Sacre Coeur. The local government asked for the schools back so that the kids could go back to class. A large tent hospital has been set up in a courtyard across from the hospital. After the experience with the man requiring prolonged ventilation and the risk of running out of oxygen, one of the doctors did some internet research and found a oxygen generator of sufficient size to provide oxygen for the hospital. Over $200,000 was raised to buy the device, which is now at the hospital in Haiti. The hospital continues to get donated supplies, including a portable ultrasound machine and portable X-ray machines. As the hospital has become a referral center for all of Haiti, there are plans for permanent expansion
In summary, my trip to Haiti was worthwhile and exhausting all at the same time. It was extremely rewarding to take care of people who had been through such a tragic occurrence. Their gratitude was overwhelming. It helped me to get back in touch with what being a doctor is all about, helping to take care of people in their hour of need. The smiles on the faces of the kids in the pediatrics ward made it all worth it. At the same time it was very sad to see people succumb to diseases that would be easily treatable in the U.S. It was heartbreaking to see people who had survived the earthquake die later from things like tetanus, sepsis and pulmonary embolus.
Hopefully good things will come out of this disaster, Haiti as a country may get the help it needs to eventually become a more prosperous nation. With the work of the physicians and nurses at Sacre Coeur and the influx of medical supplies and technologies to the hospital, they have a hospital in Milot to be proud of.