Patient Care

Hospitalists in Haiti


 

The patient had a number of wounds to her battered body, but her most pressing question was how to stanch the flow of milk from her breasts, recalls Lisa Luly-Rivera, MD. The woman was in an endless line of people Dr. Luly-Rivera, a hospitalist at the University of Miami (Fla.) Hospital, cared for during a five-day medical volunteer mission to Haiti in the aftermath of the January earthquake that devastated much of the country.

“She had lost everything, including her seven-month-old baby, who she watched die in the earthquake. She was still lactating and wanted to know how to get the milk to stop,” Dr. Luly-Rivera says. “I heard story after story after story like this. For me, it was emotionally jarring.”

A Haitian-American who has extended-family members in Haiti who survived the Jan. 12 earthquake, Dr. Luly-Rivera leaped at the chance to participate in the medical relief effort organized by the university’s Miller School of Medicine in conjunction with Project Medishare and Jackson Memorial Hospital in Miami. But soon after arriving in the Haitian capital of Port-au-Prince on Jan. 20 and witnessing the magnitude of human suffering there, she second-guessed her decision, wondering if she was emotionally strong enough to deal with such tragedy.

She wasn’t the only one with reservations. Some at the University of Miami Hospital were skeptical that hospitalists could help the situation in Haiti. They questioned why she and her colleagues were included on the volunteer team, Dr. Luly-Rivera says. Ultimately, she proved herself—and the doubters—wrong.

“As internists, we were very valuable there,” says Dr. Luly-Rivera, who logged long hours treating patients and listening to their stories.

Determined to do their part to help survivors of the earthquake, hospitalists across the country joined a surge of American medical personnel in Haiti. Once there, they faced a severely traumatized populace (the Haitian government estimates more than 215,000 were killed and 300,000 injured in the quake), a crippled hospital infrastructure, and a debilitated public health system that had failed even before the earthquake to provide adequate sanitation, vaccinations, infectious-disease control, and basic primary care.

“If Haiti wasn’t chronically poor, if it hadn’t suffered for so long outside of the eye of the world community, then the devastation would have never been so great,” says Sriram Shamasunder, MD, a hospitalist and assistant clinical professor at the University of California at San Francisco’s Department of Medicine who volunteered in the relief effort with the Boston-based nonprofit group Partners in Health. “The house that crumbled is the one chronic poverty built.”

The Jan. 12 quake killed more than 200,000 and toppled buildings in Port-au-Prince. Building instability has kept civilians out of their homes for more than three months.

The Jan. 12 quake killed more than 200,000 and toppled buildings in Port-au-Prince. Building instability has kept civilians out of their homes for more than three months.

Dr. Luly-Rivera checks the chart of a patient at the tent hospital in Port-au-Prince.

Dr. Luly-Rivera checks the chart of a patient at the tent hospital in Port-au-Prince.

Dr. Reyes (left) and Dr. Jaffer (right), with Barth Green, MD, chair of neurological surgery at the Miller School of Medicine, after a long day at the tent hospital.

Dr. Reyes (left) and Dr. Jaffer (right), with Barth Green, MD, chair of neurological surgery at the Miller School of Medicine, after a long day at the tent hospital.

Dr. Crocker uses a portable ultrasound machine to check out a patient at Clinique Bon Saveur, a hospital in the town of Cange, about two hours northeast of Port-au-Prince.

Dr. Crocker uses a portable ultrasound machine to check out a patient at Clinique Bon Saveur, a hospital in the town of Cange, about two hours northeast of Port-au-Prince.

Dr. Shamasunder was stationed at St. Marc's Hospital, 60 miles west of the capital.

Dr. Shamasunder was stationed at St. Marc’s Hospital, 60 miles west of the capital.

Worthy Cause, Unimaginable Conditions

Mario A. Reyes, MD, FHM, director of the Division of Pediatric Hospital Medicine at Miami Children’s Hospital, shakes his head when he thinks of the conditions in Haiti, one of the poorest nations in the Western Hemisphere. “This is how unfair the world is, that you can fly one and a half hours from a country of such plenty to a country with so much poverty,” says Dr. Reyes, who made his third trip to the island nation in as many years. “Once you go the first time, you feel a connection to the country and the people. It’s a sense of duty to help a very poor neighbor.”

This time, Dr. Reyes and colleague Andrea Maggioni, MD, organized the 75-cot pediatric unit of a 250-bed tent hospital that the University of Miami opened Jan. 21 at the airport in Port-au-Prince in collaboration with Jackson Memorial Hospital and Miami-based Project Medishare, a nonprofit organization founded by doctors from the University of Miami’s medical school in an effort to bring quality healthcare and development services to Haiti.

“There were a few general pediatricians there. They relied on us to lead the way,” Dr. Reyes says. “When I got to the pediatric tent, I saw so many kids screaming at the same time, some with bones sticking out of their body. There’s nothing more gut-wrenching than that. I spent the first night giving morphine and antibiotics like lollipops.”

Before the tent hospital—four tents in all, one for supplies, one for volunteers to sleep in, and two for patients—was set up at the airport, doctors from the University of Miami and its partnering organizations treated adult and pediatric patients at a facility in the United Nations compound in Port-au-Prince. It was utter chaos, according to Amir Jaffer, MD, FHM, chief of the Division of Hospital Medicine and an associate professor of medicine at the Miller School of Medicine. He described earthquake survivors walking around in a daze amidst the rubble, and huge numbers of people searching for food and water.

Same Work, Makeshift Surroundings

Drawing on his HM experience, Dr. Jaffer helped orchestrate the transfer of approximately 140 patients from the makeshift U.N. hospital to the university’s tent hospital a couple of miles away. He also helped lead the effort to organize patients once they arrived at the new facility, which featured a supply tent, staff sleeping tent, medical tent, and surgical tent with four operating rooms. Each patient received a medical wristband and medical record number, and had their medical care charted.

An ICU was set up for those patients who were in more serious condition, and severely ill and injured patients were airlifted to medical centers in Florida and the USNS Comfort, a U.S. Navy ship dispatched to Haiti to provide full hospital service to earthquake survivors. The tent hospital had nearly 250 patients by the end of his five-day trip, Dr. Jaffer says.

Hospitalists administered IV fluids, prescribed antibiotics and pain medication, treated infected wounds, managed patients with dehydration, gastroenteritis, and tetanus, and triaged patients. “Many patients had splints placed in the field, and we would do X-rays to confirm the diagnosis. Patients were being casted right after diagnosis,” Dr. Jaffer says.

Outside the Capital

Hospitalists volunteering with Partners in Health (PIH) were tasked with maximizing the time the surgical team could spend in the OR by assessing incoming patients, triaging cases, providing post-op care, monitoring for development of medical issues related to trauma, and ensuring that every patient was seen daily, says Jonathan Crocker, MD, a hospitalist at Beth Israel Deaconess Medical Center in Boston.

Dr. Crocker arrived in Haiti four days after the earthquake and was sent to Clinique Bon Saveur, a hospital in Cange, a town located two hours outside the capital on the country’s Central Plateau. The hospital is one of 10 health facilities run by Zamni Lasante, PIH’s sister organization in Haiti. Dr. Shamasunder, of UC San Francisco, arrived in the country a few days later and was stationed at St. Marc Hospital, on the west coast of the island, about 60 miles from Port-au-Prince.

At St. Marc’s, conditions were “chaotic but functioning, bare-bones but a work in progress,” as Haitian doctors began returning to work and Creole-speaking nurses from the U.S. reached the hospital, Dr. Shamasunder explains. PIH volunteers coordinated with teams from Canada and Nepal to provide the best possible medical care to patients dealing with sepsis, serious wounds, and heart failure.

Hundreds of patients, many with multiple injuries, had been streaming into Clinique Bon Saveur since the day the earthquake struck. When Dr. Crocker arrived, the hospital was overcrowded, spilling into makeshift wards that had been set up in a church and a nearby school.

How to Help

How to Help

Thinking about volunteering your medical skills in Haiti? Here are some ways to prepare:

  • Update your immunizations. The list should include measles/mumps/rubella (MMR), diphtheria/pertussis/tetanus (DPT), polio, seasonal and H1N1 flu, varicella, hepatitis A, and hepatitis B.
  • Get a typhoid vaccination. An injectable vaccine might be the best bet when travel is imminent. The oral vaccine requires refrigeration and four tablets taken every other day for seven days.
  • Pack for the outdoors. Remember to include insect repellent, long pants, long-sleeved shirts, and an antimalarial drug such as atovaquone/proguanil (Malarone), chloroquine, doxycycline, and mefloquine.
  • Bring Cipro for traveler’s diarrhea.
  • Review travel guidelines. These include frequent hand-washing, avoidance of undercooked meats and unpeeled produce, and sleep in a bed covered by a mosquito net.

Source: University of Miami Miller School of Medicine

“As a hospitalist, my first concern upon arrival was anticipating the likely medical complications we would encounter with a large population of patients having experienced physical trauma,” Dr. Crocker says. “These complications included, namely, DVT and PE events, compartment syndrome, rhabdomyolysis with renal failure, hyperkalemia, wound infection, and sepsis.”

After speaking with their Haitian colleagues, PIH volunteers placed all adult patients at Clinique Bon Saveur on heparin prophylaxis. They also instituted a standard antibiotic regimen for all patients with open fractures, ensured patients received tetanus shots, and made it a priority to see every patient daily in an effort to prevent compartment syndrome and complications from rhabdomyolysis.

“As we identified more patients with acute renal failure, we moved into active screening with ‘creatinine rounds,’ where we performed BUN/Cr checks on any patient suspected of having suffered major crush injuries,” says Dr. Crocker, who used a portable ultrasound to assess patients for suspected lower-extremity DVTs. “As a team, we made a daily A, B, and C priority list for patients in need of surgeries available at the hospital, and a list of patients with injuries too complex for our surgical teams requiring transfer.”

Resume Expansion

Back at the University of Miami’s tent facility, hospitalists were chipping in wherever help was needed. “I cleaned rooms, I took out the trash, I swept floors, I dispensed medicine from the pharmacy. I just did everything,” Dr. Luly-Rivera says. “You have to go with an open mind and be prepared to do things outside your own discipline.”

Volunteers must be prepared to deal with difficult patients who are under considerable stress over their present and future situations, Dr. Luly-Rivera explains. She worries about what is to come for a country that’s ill-equipped to handle so many physically disabled people. For years, there will be a pressing need for orthopedic surgeons and physical and occupational therapists, she says.

Earthquake survivors also will need help in coping with the psychological trauma they’ve endured, says Dr. Reyes, who frequently played the role of hospital clown in the tent facility’s pediatric ward—just to help the children to laugh a bit.

“These kids are fully traumatized. They don’t want to go inside buildings because they’re afraid they will collapse,” he says. “There’s a high percentage of them who lost at least one parent in the disaster. When you go to discharge them, many don’t have a home to go to. You just feel tremendous sadness.”

Emotional Connection

The sorrow intensified when Dr. Reyes returned to work after returning from his trip to Haiti. “You can barely eat because you have a knot in your throat,” he says.

Upon her return to Miami, Dr. Luly-Rivera spent almost every spare minute watching news coverage on television and reading about the relief effort online. It was difficult for her to concentrate when working, she admits.

“It wasn’t that I felt the patients here didn’t need me,” she says. “It’s just that my mind was still in Haiti and thinking about my patients there. I had to let it go.”

Feelings of sadness and grief are common reactions to witnessing acute injuries and loss of life, says Dr. Jaffer. Some people react by refusing to leave until the work is done, or returning to the relief effort before they are ready.

How to Help
When I got to the pediatric tent, I saw so many kids screaming at the same time, some with bones sticking out of their body. There’s nothing more gut-wrenching than that. I spent the first night giving morphine and antibiotics like lollipops.

—Mario Reyes, MD, FHM, director, Division of Pediatric Hospital Medicine, Miami Children’s Hospital

“Medical volunteerism shows you there is life beyond what you do in your workplace. It allows you to bridge the gap between your job and people who are less fortunate. The experience can be invigorating, but it can also be stress-inducing and lead to depression,” Dr. Jaffer says. “It’s always good to have someone you pair up with to monitor your stress level.”

After taking time to decompress, Drs. Luly-Rivera and Reyes plan to return to Haiti. They hope healthcare workers from all parts of the U.S. will continue to volunteer in the months ahead. Haiti’s weighty issues demand that non-governmental organizations (NGOs) working in the country stay and better coordinate their efforts, Dr. Reyes says.

“Ultimately, it is going to be important for any group present in Haiti to work to support the Haitian medical community,” Dr. Crocker adds. “The long-term recovery and rehabilitation of so many thousands of patients will be possible only through a robust, functional, public healthcare delivery system.”

It remains to be seen how many NGOs and volunteers will still be in Haiti a few months from now, the hospitalists said.

It’s always a concern that the attention of the global community may shift away from Haiti when the next calamity strikes in another part of the world, Dr. Jaffer notes. If the focus stays on Haiti as it rebuilds, then possibly some good will come out of the earthquake, Dr. Luly-Rivera says. But if NGOs begin to leave in the short term, the quake would only be the latest setback for one of the world’s poorest and most underdeveloped countries.

Even if the latter were to happen, Dr. Luly-Rivera still says she and other volunteers make a difference. “I’m still glad I went,” she says. “The people were so thankful.”

“You see the best of the American people there,” Dr. Reyes adds. “It’s encouraging and uplifting. It brings back faith in the medical profession and faith in people.” TH

Lisa Ryan is a freelance writer based in New Jersey.

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