Navy Anesthesiologists Respond to Haitian Earthquake
USNS Comfort T-AH 20
15 February 2010
On Wednesday, January 13, 2010 the hospital ship, USNS Comfort was tasked with providing disaster relief and medical support to Haiti after a 7.5 magnitude earthquake devastated much of the island’s population center. The ship left the Port of Baltimore early the following Saturday with three anesthesiologists and three nurse anesthetists (CRNA) from the National Naval Medical Center in Bethesda, MD and one CRNA from the Naval Medical Center in Portsmouth, VA. As the scope of the devastation in Haiti became clear, a greater need for operative capacity aboard was recognized and an additional four anesthesiologists and four CRNAs flew to Haiti and joined the crew shortly after our arrival.
The first wave of patients arrived from the USS Carl Vinson, an aircraft carrier with limited medical assets that was initially diverted to the area. Soon thereafter, the ship received a large volume of casualties from both Haitian and relief organizations on the ground. In its Operating Room Complex, the USNS Comfort has eleven operating rooms and one Interventional Radiology suite. Ten rooms were routinely staffed with two of these rooms operating around the clock and one reserved for patients with tuberculosis. We also responded frequently to airway issues and "code blue" calls on the patient wards and in the CASREC (Casualty Receiving) area. In addition, due to the high volume of dressing changes to wounds and burns, we also operated an "on-the-fly" sedation service throughout the ship.
By the end of the first week of extremely long and emotionally exhausting days, we received some relief from civilian providers. Among them, a pediatric anesthesiologist with Project Hope from Massachusetts General Hospital arrived early, ready to work. Several days later, more anesthesia providers arrived from Johns Hopkins, Operation Smile, and Project Hope. Their presence allowed us to decompress our schedule significantly over the following weeks. It also afforded us the opportunity to focus more on regional anesthesia to assist with pain management. We utilized both nerve stimulators and a ultrasound machine to facilitate our use of regional techniques, performing peripheral nerve blocks in children and adults both awake and under general anesthesia without any apparent complications. We quickly determined the use of regional anesthesia was of significant benefit in addressing the pain management needs of the patients as well as alleviating this burden from the overwhelmed nursing staff as the ship became the busiest orthopedic trauma hospital in the region, and possibly the United States. Of note, during the first three weeks of the mission, named "Operation Unified Response", we completed nearly 700 surgeries and approximately 50 anesthetic interventions in the patient wards and the CASREC area. The majority of these cases were orthopedic trauma involving extremity and pelvic injuries and included repairs of 33 pelvic fractures and more than 100 femur fractures. In addition to the orthopedic cases, we performed 16 burn debridement procedures, 16 craniotomies, 44 spine surgeries and 75 head and neck procedures. To our knowledge, this level of activity had never been accomplished before on a hospital ship.
Throughout the mission, we encountered several issues unique to the ship as well as the disaster, itself. Among the more prominent of these were issues of equipment and supply, language barrier, unusual pathology, and utilization of personnel.
Obtaining consumable supplies quickly became a major obstacle as we began to operate a high volume trauma service without the ability to replenish supplies in a completely reliable or prompt manner. Out at sea and without the benefit of domestic mail services, supplies were routed through Guantanamo Bay, Cuba, then to Port Au Prince, and finally to the ship via helicopter or boat. Supplies would arrive but we were never sure just what was coming. We rapidly adapted to life without fentanyl, temperature probes, and suction catheters. Other items, such as endotracheal stylets, face masks, and anesthesia circuits were cleaned and reused. One unique item that became a critical necessity was the "C-arm" fluoroscopy machine. We started with three units, two large and one small. We quickly realized during the first week that we could not continue without more of these. Three additional units were delivered to the ship the following week and surgery continued.
Other essential services such as blood supply and oxygen were reviewed prior to our arrival in Haiti to better address any potential problems. Our blood bank started the mission with 50 units of fresh packed red blood cells (RBCs), 250 units of frozen packed RBCs, 120 units of fresh frozen plasma and 14 units of cryoprecipitate and no platelets. Initially, there was concern over the use of frozen blood with regard to its quality as well as the need for special reagents to process it before use. However, we quickly received additional supplies of fresh blood and platelets and fortunately, our transfusion requirements never overwhelmed the supply. The ship has an oxygen generating plant and oxygen is available throughout the ship via a pressurized wall system. The supply of oxygen has typically not been an issue during previous humanitarian missions. For this mission however, we were not sure just what to expect but we were sure we would be busy and would need our oxygen capacity at 100%. Because of the urgency and quick response of the mission, we arrived in Haiti without full oxygen generating capacity to the wall system. So, for the first 24 hours following our arrival in Haiti, we relied upon large oxygen H-cylinders, a back-up system for emergency situations, to supply the ship and power the anesthesia machines. This back-up system functioned flawlessly until our wall capacity reached 100 percent.
The language barrier presented a series of obstacles as well. The native language of Haiti is Creole which bears enough similarity to French that several of us could muster up rudimentary phrases to engage in basic greetings. However, for any history, exam or consent, a translator was always required. Numerous translators, both military personnel and Haitian volunteers, were utilized and a translation guide was quickly generated and distributed throughout the ship. Still, the general intensity of the first few days, along with the language barrier, made it difficult at times to locate patients in the many wards on the ship and contributed to numerous NPO violations. In the evening, a nightly prayer was said both in Creole and English. To help maintain NPO status, the Creole version ended with "and if you’re having surgery tomorrow, please don’t eat."
The mission presented us with a spectrum of pathology not frequently seen in the United States. Many of our initial procedures were life or limb salvaging operations requiring active and aggressive resuscitation during surgery. Traumatic amputations, crush injuries, gas gangrene, horrific open fractures, and maggot infested wounds were not uncommon. Also common were head and spine injuries. During the first week, we performed many amputations. Though we worked tirelessly to save as many limbs as possible, the one to two weeks that elapsed prior to receiving treatment made many of the limbs unsalvageable. Fortunately, the number of amputations dramatically decreased after that first week. Other situations that presented a challenge were the pregnant patients with significant pelvic fractures. These patients required delivery of their babies by Cesarean section under general endotracheal anesthesia followed by open pelvic fixation. The cry of the new born babies surely lifted our spirits in the midst of so much despair. Lab abnormalities abounded. We found the level of anemia and electrolyte imbalance tolerated to be astounding. Hemoglobin levels between 4.0 and 6.0 g/dl were not uncommon as well as potassium levels greater than 8.0 mEq/L in many patients one to two weeks from sustaining crush injuries. All patients were without evidence of shock or cardiac dysrhythmia. One obstetric patient presented with a hemoglobin level of 2.5 g/dl following placental abruption and premature delivery. Many of these patients required intraoperative resuscitation with blood transfusion and treatment for hyperkalemia. Also, in addition to the significant orthopedic and neurosurgical trauma, one unusual disease presented a dilemma for us, acute tetanus with generalized rigidity and "lockjaw". Because routine vaccination is not available in Haiti, numerous patients presented with this disease which is rarely seen in developed countries. None of us had seen tetanus before but were fortunate to have textbooks on hand with cursory reviews of the disease and its anesthetic implications. Airway management in these patients was a challenge and whenever possible we elected to maintain spontaneous respiration using laryngeal mask airways or mask general anesthesia with an oral airway in place. Concerned with the potential for prolonged ventilatory support, we avoided endotracheal intubation in these patients. We experienced no acute airway complications with these patients. In fact, to date we have not had a single intraoperative patient death despite the horrific state of their injuries.
Finally, another factor unique to the mission, but not to the military, was the manner in which personnel were mobilized and utilized. Many of us had a 48 hour notice before departing and many others had even less time. Most of us met for the first time on the ship. We came together from different hospitals and with different skills but all with one purpose – to do our best to bring hope and relief to the people of Haiti. We worked together as a team as if we had been together for a long time. To do this required patience, flexibility, mutual respect and trust in each other. We had plenty to spare. In addition to our military personnel, we received a tremendous outpouring of support from volunteer organizations, such as Project Hope and Operation Smile and various medical institutions both private and public, including Massachusetts General Hospital, John Hopkins and the University of California in Los Angeles. In particular, the team of civilian orthopedic surgeons who arrived after the first week was a tremendous help and was invaluable in our effort to complete all the necessary surgeries in a timely manner. We are grateful for all the assistance we have received from our civilian volunteers. Our success is due to their efforts as well.
It has been thirty days now since we set sail from Baltimore, MD and the pace has slowed considerably. Some staff have gone while others continue to arrive. The people of Haiti continue to demonstrate a resilience that has been quite remarkable. While ethical dilemmas remain, no one has any doubt that this mission was the "right thing to do". As we look back and reflect upon what we’ve seen, the lives we’ve touched and the many challenges we’ve faced, we take pride in being part of something that has never been done before. We are amazed by what we’ve accomplished here in Haiti in such a short time, but not surprised. For this is Navy Medicine and this is what we do best. Hoorah!
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Drs. Benjamin, Roberts, and Solomon are staff anesthesiologists from the National Naval Medical Center in Bethesda, MD.
Dr. Roberts is Assistant Professor and Clinical Director of Obstetric Anesthesia, NNMC and Department Head, Anesthesiology, USNS Comfort T-AH 20, "Operation Unified Response" Haiti, 2010.
Dr. Solomon is a pediatric anesthesiologist and Clinical Director of Pediatric Anesthesia at NNMC and the Walter Reed Army Medical Center, Washington, DC.
Drs. Bastien and Wilber are staff anesthesiologists from the Naval Medical Center, Portsmouth, VA.
Dr Bastien is the Chairman of Anesthesiology and the Navy Anesthesia Specialty Leader.
Dr. Wright is a staff anesthesiologist from the Naval Hospital, Pensacola, FL.
Dr. Rodriguez is a staff pediatric anesthesiologist from the Naval Hospital, Jacksonville, FL.
Department of Anesthesiology, USNS Comfort T-AH 20, Operation Unified Response, Haiti 2010
John Benjamin, MD (first row, left), Gabriel Rodriguez, MD (second row, first left), Monte Wilber, MD (second row, second left), Laura Roberts, MD (second row, center), John Bastien, MD (third row, first left), Chris Wright, MD (third row, second left), James Solomon (not pictured)