A Descent Into Apocalypse:
Emergency Physicians Respond to Haitian Earthquake Catastrophe
Article Outline
From the darkened skies, few lights were visible below, only the eerie glow of hundreds of small bonfires scattered on the hills ringing Port-au-Prince, the devastated capitol of Haiti. Late in the Embraer 190's descent the jet suddenly jerked upward, away from the runway, finally to land on its second pass as the pilot slammed the plane's breaks. It was 6 days after the catastrophic January 12 earthquake. The first foreign doctors were arriving in the devastated country, and Chip Lambert, MD, was among them.
He had hitched a ride on a plane carrying Pennsylvania Governor Edward Rendell, who spearheaded a mission to rescue 54 children from an orphanage run by 2 Pittsburgh women. For Dr. Lambert it was a one-way trip. Shortly the plane would return to the United States, with orphans seated in the places occupied by him and his 2 tons of medical supplies. Dr. Lambert, who burned out as a full-time emergency physician after 20 years of practice in the early 1990s and has since performed missionary work, was bound for Léogane, a town of 50,000 just 20 miles west of Port-Au-Prince. An estimated 80 percent of the town, located near the epicenter of the earthquake that killed at least 200,000 people and injured another 300,000, was destroyed.
In Léogane, the Presbyterian Church's Medical Benevolence Foundation, of which Dr. Lambert is a director, had built the country's only 4-year nursing school. When most of the town had fallen, the school built to American codes with reinforced concrete stood as a beacon. People from the surrounding areas had flocked to the building. A veteran of decades of emergency responses, Dr. Lambert has seen the aftermaths of any number of natural disasters, from Hurricane Katrina to the Sumatran tsunami to Hurricane Mitch in Nicaragua. Nothing compared to what he saw in Haiti.
“This was, by far, the most grueling experience I have ever had,” he said of his 2-week mission. “It was a lot more chaotic in Haiti, and that's a product of it being the poorest country in the Western Hemisphere. To give you an idea, on its best day the power grid itself at the nursing school worked for 4 hours a day. And that was before the earthquake, of course.”
So it went in a country shattered by an earthquake, bereft of resources and lacking even the most essential of needs: food, water and shelter.
Emergency Physicians Respond En Masse
Although the exact numbers will never be known it seems clear that hundreds, and more likely thousands, of emergency physicians responded to the Haitian earthquake in January and February, freely giving their time and toil.
In February the United Nations Office for the Coordination of Humanitarian Affairs raised its appeal for financial help to $1.44 billion, the largest ever for a natural disaster. The United Nations stated that 3 million people were affected by the disaster, or about 30% of the nation's population. Following the earthquake many had lost homes or were trapped inside them when the shaking began. Initially the victims sustained crush injuries, broken bones, soft-tissue injuries, compartment syndromes, and spinal cord injuries. As best they could manage, the victims and their families stumbled into under-staffed, severely limited medical facilities.
Days later when international physicians began arriving, Haiti became a place where the do-it-all triage and surgical skills of emergency medicine were much in demand. For those who went, the pace was relentless: Triage. Work, from dawn until dusk. Pain, suffering, misery everywhere. Out of this cauldron of tragedy and despair many of the emergency physicians who responded discovered an inner truth.
Isolated from a world filled with paperwork and insurance battles, they were reminded why they chose emergency medicine as a profession.
“There's no question that being a doctor in a circumstance like this grounds you rapidly in why it is you went into medicine in the first place,” said Paul S. Auerbach, MD, a Professor of Surgery, Division of Emergency Medicine at the Stanford University School of Medicine.
“This was all about helping people and relieving suffering. It was about the people we took care of, it wasn't about us. Every single patient capable of thanking us, thanked us. The families and the patients endured enormous physical and emotional suffering, and they were the toughest people I've ever met. It was a terribly uncomfortable environment for them. It was hot. It was crowded. We didn't have enough pain medication, and they were all gracious to us. Everyone.”
Dr. Auerbach arrived on February 17, less than 5 days after the earthquake, with 3 other Stanford physicians and four registered nurses. Working with the International Medical Corps (IMC), a non-profit humanitarian organization, the Stanford team had flown into Santo Domingo, Dominican Republic, the day before, and boarded a bus on an all-night drive across the border into Port-Au-Prince.
The Apocalypse
“The scene on the streets of Port-Au-Prince was unsettled,” he said. “Weaving through the streets it was really like an apocalypse.”
The team was bound for University Hospital, the city's largest. They arrived to find a handful of doctors and nurses in the mostly destroyed facility. Most of the medical staff had left because they had suffered personal tragedies. Nevertheless, some 800 victims awaited medical care. Nearby, outside a crushed building, there remained 40 dead bodies. The team did the only thing they could. They began to work.
They unpacked the supplies they either brought from Stanford or purchased in the Dominican Republic–antibiotics, wound closure materials, splints, IV setups and bone saws. And they set about trying to save limbs and lives. At this point, more than 4 days after the natural disaster, many open wounds had become infested with maggots. The team worked until dark to clean and dress the worst wounds and prepare the patients for amputations. It was, Dr. Auerbach said, battlefield medicine. When night fell the team was advised to leave the hospital for security reasons.
Over the next 2 weeks other physicians arrived and Auerbach, designated the lead medical officer for IMC on site, worked with the hospital administration, many NGOs and volunteer medical teams from around the world, and the US military to create a medical center out of virtually no resources. Working together they set up tents, brought in stretchers, established a nursing staff and a 24-hour rotation, created a blood bank and an emergency department equivalent, and arranged for communications, sanitation, food and water.
“All the doctors from every institution, the numerous emergency physicians from other countries, everyone worked hard,” Dr. Auerbach said. “Although everyone was exhausted, they did what they were asked to do without fail. Sometimes that meant not doing strictly emergency medicine. Maybe it was electrical and plumbing work. It got done.”
According to the IMC, the organization brought in 150 doctors and nurses during the first 6 weeks of the crisis, most on 2-week rotations, and planned to continue to send 25 new medical personnel in each week. About 90% of respondents come from the emergency department, said Margaret Aguirre, director of communications for IMC. She, as well as representatives from the United Nations and World Health Organization, hesitated to estimate the total number of doctors who responded, but about 160 organizations were participating in the United Nations cluster meetings on Haiti response.
Doctors came to Haiti by any means they could, but not all the facilities they found were engulfed in chaos. At the island's north end, in Milot, one of the nation's largest private hospitals remained standing, and had electricity and communications capabilities. At the Hôpital Sacré Coeur, a Catholic facility, Jeremy Gabrysch, MD, worked with a couple dozen American medical professionals under the supervision of Massachusetts physician Peter Kelly, MD. President of the Center for the Rural Development of Milot, which administers the hospital, Dr. Kelly was in Haiti to perform eye surgeries when the earthquake struck.
Helicopters from various armed forces delivered 200 or more patients a day to the facility, recognizing it as one of the few fully functioning medical centers in the country, Dr. Gabrysch said, and probably the largest until the arrival of a US Navy hospital ship, the Comfort, on January 20.
“Since we weren't at ground zero I didn't witness the destruction and the emotional trauma first hand,” said Dr. Gabrysch, an emergency physician at Seton Medical Center in Austin, TX.
From a disaster response perspective, being in a more controlled setting, Dr. Gabrysch said he sees the establishment of facilities away from ground zero as a valuable supplement to the more chaotic field hospitals at or near the disaster location. Instead of treating patients on site, he said, it's probably best to work on transporting patients to more stable facilities.
The Milot hospital only assumed a valuable role because of the willingness of the military to transport patients, and Dr. Auerbach and his colleagues from Stanford and elsewhere noted in a New England Journal of Medicine Perspective (10.1056/NEJMp1001555) that the civil military collaboration worked very well during the initial medical response to Haiti.
“We are aware of the complexity and sensitivity of interactions between nongovernmental organizations and the military,” the authors wrote. “Nobody is perfect, and neither were we. But in this disaster response, the collaborative interaction between civilian medical teams and the military in responding to the initial casualties of the Haiti earthquake could serve to inform policies and procedures for future disasters. Working together, we achieved order out of chaos.”
One lesson Dr. Auerbach said he learned is that a clear delineation of responsibilities among agencies during disasters makes a significant difference in the effectiveness of response.
Hard work and dedicated NGOs make a big difference too, said Dr. Lambert. Twice during his 2-week mission, he said, working with the Pittsburgh-based Brother's Brother Foundation and other groups, 737 aircraft were packed with 30,000 pounds of cargo and flew into Haiti.
“All of the medical supplies on these aircraft were worth an incredible amount of value,” Dr. Lambert said. “There was $2 million worth of ketamine, and all kinds of other pharmaceuticals. We literally had enough ketamine to do 5,000 cases. We were good to go after that.”
But getting the supplies to the patients who needed them was often tragically difficult. Melissa Barton, MD, made it to Haiti by way of a National Football League player whose name she had never before heard. Now, Dr. Barton said, she'll never forget the name of Gosder Cherilus, an offensive tackle for the Detroit Lions who was born in Haiti and lived there until the age of 14. Cherilus financed the mission, and Dr. Barton reached Port-Au-Prince on January 23 with about a dozen colleagues to begin working at L'Hôpital de la Communauté Haïtienne in the capital city.
Highs and Lows
During her 5-day mission, the experiences of Dr. Barton, Program Director of the Wayne State University/Sinai-Grace Hospital Emergency Medicine Residency Program and President-Elect of the Michigan College of Emergency Physicians, illustrate the extremely emotional highs and deep lows experienced by physicians responding to natural disasters.
A notable success came when physicians were able to help an 18-year-old boy with tri-lobar pneumonia at a time when there were no ventilators available in the city. Dr. Barton said initial efforts to transfer the boy to a US hospital, where his care would have been routine, fell through. As the boy lay on a mattress on the floor with the hospital's last oxygen tank nearly depleted, Dr. Barton says she wept. But at nearly the last moment an Army team the doctors had previously met came up with a ventilator. The boy's life was saved.
Earlier during Dr. Barton's stay, however, a 31-year-old woman was not as fortunate. The patient had difficulty breathing and severe pneumonia, Dr. Barton recalled. With no ventilators she, too, was placed on oxygen. Other specialists determined the woman likely had active tuberculosis, and she had to be put into isolation. But how?
“The hospital was not only full but overwhelmed,” Dr. Barton said. “Patients were sleeping on the floors. There was no room. They were in the hallways. But there was a broom closet about 20 feet outside the door to the ICU.”
That's where Dr. Barton found her patient when she came to the hospital on the ordeal's second night. Haiti is sultry even after sunset, and the patient was sweating as she sat on her cot, holding her oxygen mask tightly. With a cot squeezed in, the small room, about 8 feet by 3 feet, was just wide enough to admit Dr. Barton if she pressed her back against the wall. No windows. No “call light.” The night came and went.
When Dr. Barton returned the next evening at 5 PM, the ICU nurse was in tears.
“Her husband had went into the room around 3 PM, and she was on the ground dead,” Barton said. “Alone and dead. In this small cramped room. Yet the entire time during her stay, she sat quietly, quiet but scared, holding her oxygen mask. Waiting. Waiting for something to happen, some additional help to arrive or resource, though I'm not sure she really understood why nothing more was happening for her, but she seemed to accept the amount of care being provided. That was what was striking and unforgettable in the hospital. The quietness at nighttime given the number of people there, their pain and the uncertainty.”
Section editor: Truman J. Milling, Jr, MD
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The author has stated that no such relationships exist. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement.
PII: S0196-0644(10)00264-7
doi:10.1016/j.annemergmed.2010.03.019
