Trip Report Dr Ernest Benjamin Feb. 2010

Report of Ernest Benjamin, MD FCCM
Professor of Surgery and Anesthesiology
Chief, Division of Surgical Critical Care Medicine
Dear Eric , Colleagues of AMHE

I have just returned from 13 days at the General Hospital in Port-au-Prince. I
thought you would be interested to hear from a direct eyewitness and a
participant how things went and what the perspectives are likely to be.
I was very happy to see how actively the AMHE has overcome obstacles and difficulties to establish an indispensable and strong foothold on the ground. I think expatriate Haitian physicians, nurses and other health care professionals have a natural stake in any health care happenings in Haiti, whether they are natural or man-made disasters, or whether we are talking about health care development projects in the motherland. The AMHE can position itself to be that obligatory actor and partner, if it demonstrates that it can rise up to the many challenges that it faces in dealing with the powerful actors, both local and international, who also have a stake in the fate of the Haitian health care system.

Before getting into the observations I want to make, I am happy to report that,
despite an unusually long delay before actual help got to the population, the
Haitian people has shown a tremendous courage, civism and patience. It has
remained absolutely calm ad patient throughout the country, despite the escape from jail of more than 4,000 prisoners, including some very nasty criminals. As could be predicted by whoever truly knows Haitian people, notwithstanding its turbulent recent past, Haitians are a very peaceful people. Crime used to be almost unheard of, in the past. In this most challenging circumstance in its entire existence, the Haitian people has demonstrated a beautiful example of solidarity and civility.

In collaboration with Partners in Health (PIH), I went to Haiti on Friday
January 15, three days after the quake, to assess the situation and prepare for
the arrival of a more substantial mission (30 professionals) from The Mount
Sinai Medical Center. Together with some PIH collaborators, including doctor
Mark Hyman, (Family Practice and ER), his wife, doctor Pier Boutin and her
father doctor George Boutin, (both orthopedists from Florida), a nurse
anesthetist and an OR nurse, Dr. Jean Louis Dupiton and I (both of us
intensivists from the Sinai system) created an improvised team that set out to
organize the first makeshift ORs and deliver the first surgical and
perioperative care at the University Hospital. We had brought along substantial amounts of medical and surgical supplies to enable our operation and establish a makeshift ICU. Later on, other teams came from all over the world, including the first AMHE delegation .

My first observation is that this earthquake ranks among the deadliest ever,
worldwide. The 16:53 pm quake occurred right in the middle of afternoon classes, trapping countless students and teachers under the rubbles of the 95% or so of schools. In addition, workers, employees, hotel guests, everybody got trapped under large chunks of debris from collapsed poorly built houses and buildings. More than two weeks after the quake, the overwhelming majority of the collapsed dwellings are still the way they were on day one, with untold numbers of bodies trapped underneath. Which means that the current official figures of “more than 150,000 people already buried”, as declared by the Information Minister last Friday, are likely to be just a fraction of the real casualties figures, which will never be known. When we arrived at the General Hospital 3 days after the quake, hundreds and hundreds of bodies were piling up in the hospital yards. They were subsequently removed every night using tens of heavy duty dump trucks. Just keep in mind that every 100,000 correspond to about 1% of the entire Haitian population.

My second observation is that this earthquake, as the most dramatic catastrophe ever in our history has flashed a bright light on us and reveal to the world the naked truth about the depth of our misery. No longer can we pretend that everything is OK. The Haitian “White House” lays in ruins without any effort ever made to even attempt the rescue of anybody who happened to be trapped there to die, even if uninjured. There was no difference between rich or poor: same unpreparedness, same calamity, same fate. No longer can impressive titles such as “Hôpital de l’Université d’Etat” impress anybody or hide the abject poverty of an institution which, despite its calling as a temple of caring, teaching and researching, was totally ill-prepared to do any of these tasks. This hospital was an utter disaster way before disaster struck on that fateful Tuesday afternoon.

We organized the first makeshift operating theaters in the Dermatology building and performed the first cases before we were joined by teams from Médecins du Monde, International Medical Corps, the Swiss Red Cross, the Norwegian Red Cross, the Belgian Red Cross, the AMHE, Médecins Sans Frontières, to name just a few organizations. We cared for very few head, chest or abdominal trauma. Not because these injuries did not occur, but very few people would survive them for three days without any help being provided. Most of what we had to deal with were badly infected and necrotic open limb fractures, often multiple. For these patients, amputation was the only way to save the victims’ lives. A large percentage of fasciotomies/debridements done as an attempt to save the limbs had to be converted into subsequent amputations. Anesthesia, done in the absence of electricity or anesthesia machines and in septic patients was mainly IV ketamine and propofol, with oxygen given by mask or nasal cannula. Analgesia was provided with anything that we could get our hands on: IV or PO morphine, Percocet, Tylenol. Later on, as the cases were less severely infected, we gave nerve blocks and spinals also. By then, we had already organized cleaner operating theaters, had on-and-off power and workable anesthesia machines and monitors to enable safe general anesthesia. Tetanus and DVT prophylaxis were provided as much as we could. Critical care was mostly confined to post-anesthesia care and consisted mostly in aggressive fluid management with crystalloids (there was no workable Blood Bank at the beginning, and no colloids). A few cases crush injury were treated with hemodialysis. Blood bank became available after one week.

From the beginning, I was assigned the task of organizing the post-anesthesia and postoperative care delivery. We spent tremendous amounts of energy to overcome the prevailing inertia and chaos to organize a PACU in Dermatology building and a ward for postoperative and ICU patients in the Emergency Department Building. However, the psychological trauma was such that patients did not want to be in any building. A 6.1 aftershock sent both patients and staff outdoors and, despite positive engineering inspections by the US Army Corps of Engineers and other foreign safety professionals attesting to the safety of the building, patients and local staff refused to re-enter the building. By the second day, the difficulty of having anything done, be it electricity, water, sanitation, food and drink for patients and staff, or transportation, was such, that we requested the direct assistance of the US military on the hospital ground. They were extremely useful in providing MREs (Meals Ready to Eat), water, order and patient transportation. With respect to setting up an ICU, we were not able to do it. Although we identified and cleaned the space, we ran into a logistical nightmare, which included unreliable electrical supply, difficulty of providing ventilation or air conditioning, absence of running water, etc. However, the need for an ICU is currently great and it should be included in the list of priorities.

With so many players coming to such a chaotic place from so many different parts of the world, it was quasi unavoidable that misunderstanding and hurt
sensitivity would occur. For example, the first surgical team could not
understand that a surgical resident would stop working by 3:30 in the afternoon, stating that his time was up, while that day, we worked until 9:30 at night. Similarly, the residents could not understand that, with so much work to do, they would be left aside if they did not actively try to join the action.
Perhaps, the integration of the residents would have been smoother if the local attendings themselves had not been a no-show. Similarly, I believe that a few AMHE members who had traveled there, overcoming great difficulties, did not quite seem to understand that the international teams did not run into oblivion or blend into the decor to make room for them. Other AMHE members displayed a profound sense of humility and worked tirelessly along with their international colleagues. In fairness, we have to understand that everybody was stressed by the situation and I believe that things substantially improved after the first couple of days.

Currently, there is no shortage of doctors on the grounds. There is a need for
many more nurses. With teams coming from all parts of the world, there is a
great deal of egos over there, of people who don’t quite appreciate the value of humility. It’s very important to have a cooperation of all the teams present
there and between them and the local doctors. A few of the international
surgeons have had the attitude of saviors parachuted in a land full of savages
with whom they do not want any contact and for whom they pay no respect
whatsoever. This has been very counterproductive and we have tried to work on smoothing the relationships, but more work needs to be done in that respect. However, it is fair to mention that this negative attitude was coming from very few individuals. The great majority of the international professionals performed with remarkable humility and collegiality. Along these lines, it is worth mentioning the hypocritical attitude of totally relying on the US Army personal to move patients, provide security and order, provide staff and patients with food, drink, medications, surgical supplies, tents and the like, and yet, get offended if in very rare instances, an occasional soldier behave with “disrespect” with such and such resident or doctor.

The most important lessons I learned are that, in cases of a major disaster in
places like Haiti, where the state administration apparatus was essentially
non-existent before the quake, the assumption that initial relief work would be
locally-provided until the international assistance arrives in 3 to 5 days does
not hold. There was no initial local search and rescue except for that which
was done by neighbors helping neighbors with their bare hands. There was no hospital care provided during the first 3 days because a lot of doctors and nurses died in the quake, or have lost everything and/or family members and are too traumatized to work. Also, the health care infrastructure was a disgrace before the quake, and could not be relied upon. The first 3-day window was totally lost. Absolutely no care was provided, resulting in mass casualty that for a large part, could have been avoided.

A second lesson is that it is time for us to stop pretending. If the current national trauma does not shock us into a collective awakening, nothing will. I hope that this most humbling experience will convince AMHE that the magnitude of the current challenge is too big for this organization to expect to be able to tackle it alone. AMHE should actively pursue alliances with like-minded organizations if it is to remain relevant. A chastened and renovated AMHE could be a tremendous force for progress in the national health care landscape. AMHE has the numbers, the skills and the desire. Let’s parlay that into a strong bargaining position when negotiating with the powerful forces that, maybe for the first time in our history, are readying themselves to tackle the Haitian problems.

All in all, my trip to Haiti was a most rewarding experience. I hope it was the
same for the numerous health care colleagues who accepted to share in this