Team from University of Pennsylvania
January 22, 2010
The Hospital of the University of Pennsylvania Department of Anesthesiology and Critical Care is preparing to deploy 2 members of the department, to join the 9-member Penn Team leaving for Haiti next week. The team consists (currently) of 2 anesthesiologists, 2 orthopedic surgeons, 1 trauma surgeon, 2 OR and 2 ICU nurses. This is being co-ordinated through Partners in Health.
The criteria for selection of the anesthesiologists for the first deployment included prior military experience - both are male. Dr. Thomas Floyd is a CT anesthesiologist with far-forward training, and Dr. Michael Ashburn is a pain specialist with Special Forces training. Dr Ashburn is leading the 9-member Penn Team. Penn is taking supplies with them.
In addition to providing anesthesiology and pain services, we are hoping to collect data on the resources in Haiti with a WHO "Situational Analysis" Tool.
January 25, 2010
We are now safe and sound in PoP. We are in a secure tent city. Water here, and we ate well on the plane. We gave our remaining food away to Haitians and elected to survive on Powerbars until we reach the hospital sometime tomorrow.
The drive in from the airport was interesting. Only a few lights due to limited power (mainly from generators). People out everywhere on the streets as they are afraid to sleep in their homes. Some food vendors out, especially near the airport. Tight security near the UN headquarters which is now beside the airport.
Devastation everywhere. While some buildings are standing, every block has damaged houses, some just piles of rubble.
The Haitian people we have met are very grateful and are gentle, polite people. Amazing considering the state of life they find themselves in.
All of our gear is still with us. We will sleep with the important gear, and get up early to make sure another team is not tempted. No worries, as the drugs are under the watchful eyes of the ladies (nurses) and the ortho supplies are guarded by the ortho docs. They now snarl at anyone who walks by their tent. Ha.
There are teams from several other institutions here, most of which are working in the city. They report improving supplies, but increasing frustration over poor collaboration between groups as well as critical needs such as no working autoclave in the PoP major hospital. They say that they still have several hundred patients with ortho injuries such as open fractures waiting for surgery.
The ride to the hospital we will work at is expected to take 4 hours due to the road conditions. We do not have a departure time but are hopeful it will be fairly early to allow us to start working tomorrow and to avoid travel in the heat of the day.
PS Folks are wandering around with their names and specialty on their scrubs ("Michael – Anesthesia"). Looks to facilitate role definition rather nicely.
Our preparation is being noticed. Apparently others have not arrived with bags in the team's colors. Shirts help ID the team in a crowd.
Folks wandering around in shorts and flip flops. No bugs here to speak of.
I will call tomorrow after I have confirmed where we will work and what our departure time is. I suspect this might be later in the day.
January 26, 2010
This is a church located by the hospital. It has been changed into a surgical ward and today has 55 patients. The patients are tended to by a PIH physician who is a med - peds resident. He was here at the time of the earthquake and had to quickly learn how to care for patients with orthopedic injuries.
About half the patients are children, about half of which have family with them. Injuries range from open fractures to spinal cord injuries.
Post-operative deaths have mainly been due to PEA cardiac arrest, presumably due to pulmonary embolus. They are using SQ heparin, which is very hard when 2 nurses are caring for 50 patients.
So far every single Hatian we have met - patient or staff - has lost at least 1 family member in the earthquake.
We probably will have around 10- 15 cases to do tomorrow, plus a number of wound dressing changes we will do with anesthesia. Ten cases will be ortho, about 5 general.
January 27, 2010
REPORT from PARTNERS in HEALTH HOSPITAL, Change, Haiti
From: Michael Ashburn
Sent: Wed Jan 27 07:18:29 2010
Subject: Day 3 morning report
Good morning. We had an uneventful evening. We were able to spend some time with our hosts, assisted by Prestege Beer. Between sips we put together today's OR schedule.
We posted 10 cases, 1 of which was transferred to Port au Prince last night. Cases range from a hernia repair in a 2 year-old, lots of orthopedic cases, ending with an open cholecystectomy in a pregnant HIV positive patient. In addition, our team will try to assist with dressing changes as much as possible. These folks are not able to receive analgesia-anesthesia before these procedures, and we hope to help with this.
Our hosts are incredible. The PIH staff includes volunteers who are medical students and residents. They are bright and work very hard. They made great effort to get us integrated into the flow of things, something they have to do very often as teams come and go. The local staff is also working very hard. They continue to impress us with the efforts they are making to help us help them.
In the OR we are running 2 rooms. We will be working with an anesthesiologist from Cuba, as well as CRNA students. They actually run a CRNA school here. Of course, there is the problem of not being able to say anything to them, since neither Tom or I speak Spanish or French. Lots of hand waving.
The ORs are small but functional. The anesthesia machines have Sevo and Forane. They were very happy we brought LMAs, which they prefer to use. They reuse an LMA until it wears out. Intubation is less desired. They seem interested in regional but do not seem to use it much. We will introduce it to them today, as we plan on a fem pop block for a pregnant patient.
We have identified 41 cases and have not yet seen everyone. In addition, they admit new folks daily through a small ER. I think the pace will be steady but not crushing until we leave.
Until next time
This is the emergency room for the hospital. We had an occasion to go to the ER this morning when the local team asked for our help. It consists of an entrance way and one room. It is amazing what they can do with what they have.
As you can see, lines quickly form for triage. In addition, this is where family wait as well. Two of the four areas that hold trauma and surgical patients are located in the building this photo was taken from.
Subject: Surgery has started
All patients we are operating on who are not in the building the ORs are located in are transported to the building, leading to patients everywhere.
We are running two rooms. The two ortho docs are doing their thing in one room, while we have a rather full general surgery schedule in the other. The patient below is our third case. She is a very ill young woman undergoing a cholycystectomy. Tom, 1 of our 2 Anesthesiologists, was recruited to 'first assist'. As a result, I am doing anesthesia in both rooms with the wonderful help of the local team.
Michael Ashburn, MD, MPH,
Penn Team 1 Leader
Professor, Anesthesiology, University of Pennsylvania
No view boxes in the OR, so Xrays hang from the ceiling. The ortho docs are making do with no fluro. The case they are doing now may allow the young woman to keep her leg.
January 28, 2010
Subject: Start of day 4
Good morning from the steps of the Friendship House. While waking up this morning we were met by beautiful African music coming from the church. Not a bad way to start the day.
We finished up yesterday a little before midnight. However, Derrick and Babak had to return to tend to a patient with some post- op bleeding.
We did 13 cases yesterday, including several children. Two were ASA 4, and several more were 3's. One was on a dopamine infusion (no pump) on the floor for pressure support.
Today we are working on our pacing skills, and have established a schedule we hope to follow for the remaining of our stay. Patient rounds at 0630, resupply at 0730, breakfast at 0800, team meeting at 0820, operations start at 0930, lunch- dinner at 1430, more operating in the afternoon, finish OR cases by 1900. We will work in a couple of hours of wound rounds in the afternoon.
Wish us luck!
Subject: Cases underway
Today we have scheduled 12 cases, but the cases we do change as the day progresses due to new patients as well as changes in priority.
A young woman is the fourth case of the day by our team (we are running two rooms). We are caring for several people who have undergone amputations who then become infected before they undergo final wound closure. As a result we are revising lots of these wounds, then will bring them back for washouts until clean enough to close.
The first case was a young girl with open wounds on her legs and arms.
We are hopeful she will not lose a limb, but will need skin grafts when the wounds are ready.
A Haitian colleague I am working with is intermittantly tearful. Caring for the girl was hard for her. I don't know what family members she lost, and language barriers and work environment prevent me from talking about this. However, her courage in coming to work to continue to care for these folks is amazing.
Today we gave the anesthesia team some more of the supplies we brought. They are very grateful for the gifts provided by Penn. Thank you for allowing us to provide these supplies.
We are integrating our supplies with the existing supply chain with rare exception. This is appropriate, especially given that we are the only team here operating.
Patient flow is much improved now that we know each other. It has been fun working towards integrating our team into this hospital. I would like to think that while the beer helps, ultimately it is the skills of our surgeons that did the trick. That, plus their obvious compassion and efforts to treat everyone with respect.
January 29, 2010
Subject: Her momma is dead
We are now well into our third day of surgery. We have 12 big cases and several small cases scheduled. We are trying not to do too many cases, but the local hospital is now asking us to take care of more and more people.
The hospital has stayed at 200% normal patient count, and they are admitting 10-15 patients a day as more people leave PoP. Many are trauma patients who require surgical care.
This young lady is a 12-year-old girl with a femur fracture. As she was waking up from her procedure she was calling for her momma, a term recognizable in most any language.
The response, which we have heard before, was "Her momma is dead."
We returned this young lady to a living grandmother.
Subject: A win
This is the case we are completing now this young lady has a bad open tib- fib fracture. The wound is too large to close. However, the team was able to reduce the fracture and put an EX Fix in place.
We hope to get her to the Comfort for the flap she will need to close the wound before infection sets in, as we have seen in so many of our patients.
January 30, 2010
Subject: Improvised telemedicine
We operated relatively late last night, finishing our cases around 9 PM. The good news is that the day went very well, and we did some good.
This photo is our improvised efforts at telemedicine. We are taking a photo of Xrays or wounds, then sending them via e-mail to colleagues home for suggestions. This is working out rather well.
Today we have a full OR schedule plus several dressing changes under anesthesia that we do on the floor (literally).
The team is healthy and in good spirits. None of us slept well, because the dogs and bats were out in full force. We blame the full moon.
Tom got up in the middle of the night to tell them to shut up in English. Fortunately, the dogs appear to speak English, and moved away to continue their howling.
Until next time,
January 31, 2010
Subject: Wet start
We intended to have a short day today and do only those cases that had to be done. The OR is not usually open on the weekends. However, the local team stuck by us as we operated late into the evening on Saturday, and joined us on rounds as they have every day this morning at 0630.
We were followed by a film team documenting care provided through PIH. They filmed rounds, wound rounds, as well as 1 case in the OR. It is a bit different to do a case while being filmed, but things for the most part went well.
We were met with flooded ORs when the doors were unlocked. We were able to save most of the equipment and supplies, and all the electrical equipment worked after drying out a bit.
We finished today's cases around 1 PM, and the team is looking forward to some down time today. We have a full day of cases Monday, and have scheduled cases through Friday as we try to complete surgical care on as many people as we can.
A new team from Duke will arrive sometime on Friday, which will be our last day of operating. We learned yesterday that we will return on Saturday.
I hope you have a great weekend,
Subject: FW: Empty beds
Today for the first time we found empty beds and open floor space while rounding. The inflow of earthquake trauma patients is slowing down. We are starting to see an influx of patients with a wide variety of advanced disease presenting for care.
One such patient is a young boy who appears to have advanced osteosarcoma. He has a very large lesion on his lower leg with a large solid node in his groin. We will do a biopsy tomorrow, but the outcome is poor in any country if he has the advanced disease we fear he has.
While empty beds are hopefully a good sign, this is not always the case. This was the bed for the boy who fell off the horse. He died last night at 9 PM with his mother and our nurses nearby.
Subject: Education and teamwork
Yes, Tom Floyd is a real man. Today we are doing a case that requires good muscle relaxation, which is not commonly used here. While they have ventilators on the anesthesia machine, it uses too much oxygen, which is supplied by tank and is in short supply. Therefore, when used, ventillation is by hand.
The local team does not use neuromuscular monitoring, a skill we are introducing to them. In this photo, Tom Floyd is demonstrating what a normal response is on himself. He then compared normal to the patient after vecuronium.
The local staff members are exhausted. In spite of this, and even after working late last night, their team returned early this morning to do a full day's worth of cases on a day off. The physicians joined us for rounds at 6:30, and are helping with anesthesia and scrubbed in learning from our physicians.
This includes all the support staff, including folks to clean and sterilize equipment between cases.
A very impressive group of dedicated health care providers.
February 1, 2010
Subject: Today's oxygen
I am pleased to report that the rush to the OR is slowing. We are moving from major ortho cases to wound care.
Today we will do only 3 major ortho cases; the rest are wash outs and skin grafts.
Patients and staff are tired. They are 3 weeks into the earthquake and their injury. Many have undergone several operations. Each time they wake up they have lost (literally) another piece of themselves. Tears flow easily, and for good reason.
We are doing our best to use sedation as much as we safely can. In addition, we are working hard to get wounds clean enough to graft so that these folks do not have to return again to the OR. In addition to morning rounds, we conduct "wound rounds," during which one of our Anesthesiologists and a Surgeon change dressing and tend to wounds. This allows us to plan wound care going forward and to provide sedation, especially for the children. Our Anesthesiologists are getting rather good at wound care.
Today's OR cases range in age from 2 to 36. While we have done older people, many people here are young, and we have been told the average life expentancy is 52 years.
Subject: Patient transport
These guys work very hard. Since the wards are spread out, and the hospital is located on the side of a mountain, transport is by hand.
These guys are patient and treat the patients with kindness. To date we have never waited for a patient to arrive. As long as the schedule is printed they follow it.
Very imprssive group of men.
February 2, 2010
Subject: Game changing day
Today is turning into a day of change. We woke up to find about 1,500 people sleeping around the compound. Apparently the thousands fleeing Port- Au-Prince have made it to Cange. Since there is nowhere else to go, and the compound offers some security, sleep and food, they are now here.
As a result, we are receiving an influx of injured and sick. We saw several new patients now scheduled for surgery, and expect more as people are processed through the long line that is forming in front of the Emergency Room. We have a busy day already scheduled, and expect things to get busier as the day goes on.
New issues for the hospital and our team come with the influx of so many people who need so much. The compound is making every effort to help, but there are no tents, and people are sleeping on the ground in the open. Security is increasing, and we are taking appropriate measures for our own safety. However, we have so far had absolutely no problems with personal security. We hope to keep it that way.
Rounds today included a cardiac arrest. A patient admitted for heart failure decided to quit breathing while we were rounding.
We were successful in establishing spontaneous pulse and respiration, but her future is uncertain.
In the operating room we have nine cases scheduled so far. Five are major ortho cases, the rest are skin grafts to close wounds. Two of these cases are urgent add-ons, and we are prepared for more.
The little guy in the picture is one of our success stories. The lucky children have a toy and a parent or other loved one with them. When resources exist, the family brings sheets from home for them to sleep on.
The children here are so good, considering what they have gone through. They have beautiful smiles and are very affectionate. Parents are caring and loving. Amazing people, really.
Our local physicians tell us that before the earthquake one of the major gifts to the community was a school run on the grounds.
Unfortunately, many of the teachers were in PoP at the time of the earthquake, and those that were here lost many loved ones. As a result, the school is closed with no ability to reopen anytime soon.
Until next time,
February 3, 2010
Subject: Music lessons
As more people arrive, the makings of a small community seem to form. This afternoon several groups of children of different ages are practicing outside. Our bet (not yet confirmed) is that this is the usual time for school- related music, and even though there are no teachers, the children are doing whatever parts of their normal lives that they still can.
February 3, 2010
Subject: Tank change
Sent: Wed Feb 03 11:33:09 2010
Oxygen is supplied throughout the hospital via tank. Because it is rather difficult to get heavy tanks to a fairly remote hospital in the mountains, they run the tanks dry before changing them. This does lead to rather fast tank changes in the middle of operations.
Things are a bit tired today, including the equipment. We have worn down the batteries, and did not have time between cases to get it charged. As a result, our team had to improvise and use the drill as a rather big wrench.
Another issue they struggle with are the drill bits. They have been used quite a lot, and as a result are becoming harder to use. However, overall supplies and equipment are very much up to the task at hand.
Subject: New resources
Today we continue to see patients arriving from Port-Au-Prince with un- or under- treated orthopedic injuries and wounds. The number of people living on the compound continues to grow. We were awakened this morning at daybreak (around 0500) by the sounds of many families engaged in the morning routine. This, of course, included barking dogs, roosters announcing their presence, and crying babies.
We are surrounded by life as well as suffering.
We continue to be aggressive in providing analgesia for dressing changes when necessary. In addition to the anesthesia provided in the wards, we are starting to bring patients into the OR to take down dressings following skin grafts. Many of these folks have been experiencing three weeks of pain on top of the earthquake. They have simply had enough, and do not tolerate painful procedures anymore.
Having said that, more often than not we are met with a smile, and they thank us even when we return a fairly sedated child back to Mom's arms.
Moms here are very resilient. On our second day of surgery we later discovered that we operated on a mother's two children, one of whom is an infant, at the same time.
Just to be consistent, we sedated her children this morning, one after the other, to take their dressings down. The good news is that both children are doing well.
Pulmonary embolus remains a common problem. It is difficult to get patients mobilized, and many have long bone fractures. SQ heparin is being administered when possible, but the limited availability of nurses makes this difficult at times. We have no way to confirm the diagnosis of a PE other than to rule out infection as a cause if increased RR and hypoxemia. Treatment options include IV heparin via minidrip and nasal oxygen.
Yesterday a Haitian physical therapist arrived and went right to work. He has limited supplies, but is working hard to get people up and about. Many, many people will need prosthetic care, and we have none. In the meantime we are working on getting people up and about. This young lady is a fast learner.
February 4, 2010
One issue that can be a problem within any healthcare system is patient handoff and communication among team members. This is especially difficult if the physicians and nurses speak different languages, and the medical record is in French.
When we arrived there were no written notes for us to use. Patients had no name tags and Xrays were not marked by side (i.e. left vs. right). This, plus the availability of providers to provide care, led to delays in wound dressing changes, and little planning for future care.
Several changes in the process of patient care can now be seen. X-rays have the side marked, patients now have ID tags, and we implemented a system of marking on the dressing or cast what the plan is to guide future care. In addition, with the help of our PIH partners, the incoming medical team will receive a rather detailed spreadsheet listing critical healthcare information for each patient we are caring for.
Subject: Thinning out
Today we can see that there is more room in the church, the location in which many of the trauma patients stay. Some patients with injuries too extensive for us to care for have been sent elsewhere as new additional resources become available. Others have gone home. Some remain to complete treatment, including starting rehabilitation for the loss of a limb. A few remain because they have nowhere else to go, as their home and possessions were destroyed
Today we saw one young man who can not go home because there is not enough food at home for him to eat. Other members of the family have moved in, and the family simply cannot afford to feed the people now living with them.
Tomorrow morning we have one last case to do on the operating room, as well as 16 dressing changes (three with anesthesia). We will try to get all this done to be packed and ready to catch our bus to Port-Au- Prince at 11:30. We will spend the night in a tent city, then return to the states leaving very early on Saturday morning. We don't know yet if we will make it home to Philadelphia due to the weather there, but will certainly try to get as close as possible.
February 5, 2010
Subject: Last words
We have completed our last patient rounds, which included 16 dressing changes and 2 "mini-codes" on patients in distress that we were passing by. Everything went well, and our work here us coming to a close.
Dr. Maxie, the Haitian physician who is the chief of the hospital had kind words for us thus morning. He said "God brought you to us. You have been wonderful. You are now part of Haiti."
We could ask for nothing more.
February 8, 2010
Subject: Last message
I am happy to report that Penn Team 1 arrived safely home from Haiti yesterday. Their direct flight was significantly delayed due to the "snowpocalypse" storm that closed the Philadelphia airport for several hours, but they were able to get in at 0100.
Thank you - and to the ASA - for your support of our mission.