Friday, February 19, 2010
Returning Home to Haiti
(Photo by Jennifer Carroll)
Published at www.nejm.org February 19, 2010
Returning Home to Haiti — Providing Medical Care after the Earthquake.
As I left an anesthesiology lecture on January 12, someone stopped me to ask whether I had checked on my family in Port-au-Prince. When he explained that there had been an earthquake, I breathed a sigh of relief — earthquakes, I reassured him, are a frequent occurrence in my country. It was not until I saw the news on television moments later that I realized the gravity of the situation.
Born and raised in Port-au-Prince, I completed medical school at the Université d'État d'Haiti and then served as a general practitioner for Haiti's Department of Public Health in the port city of Jacmel. When I came to Boston to start a residency in anesthesiology, I did not expect to be returning to my homeland after only 6 months of training to apply what I had learned.
I hastily prepared to return to Port-au-Prince to help in any way I could. Another Haitian resident and three faculty members from our department decided to accompany me. Together, we gathered medical supplies donated by Boston-area hospitals and took a minimum of personal items, all stuffed in duffel bags. We flew directly to Port-au-Prince on a chartered plane, arriving 96 hours after the earthquake, on Saturday, January 16.
From the airport, we traveled to a makeshift hospital where two big tents, originally intended as warehouses, were filled to capacity with earthquake victims. There were two double rows of cots set less than a foot apart from one another. Every cot held a patient, and injuries ranged from minor wounds to severe, life-threatening ones. Men, women, children, babies, elderly patients — all were crowded together in this chaotic scene. The suffocating heat and stench brought me back instantly to the harsh realities of health care in Haiti.
Most patients had limb fractures, many of which were open and infected. Others had gangrene of their limbs, necessitating immediate amputation. There was hunger, dehydration, and pain. One could hear patients screaming during dressing changes and from the pain of accidental movement of fractured body parts. Some were sobbing over loved ones they had lost. Others slept, owing to extreme fatigue, in spite of the environment.
Critically injured patients who seemed more likely to survive were transferred to better-equipped field hospitals. Those who were clearly not going to make it were hydrated and received analgesics. No supplemental oxygen was available.
When we arrived at the field hospital, no operating room had yet been set up. There were about 30 physicians and 20 nurses caring for approximately 300 patients. My anesthesia colleagues and I provided nursing care, since there was no setting in which to perform surgical procedures. We started intravenous lines and administered analgesics and antibiotics, and those of us who spoke Creole began translating for other health care personnel.
That evening, the team saw a 9-year-old boy die from sepsis due to gangrene in his arm. Surgeons and anesthesiologists then made the bold decision to amputate gangrenous limbs of young, otherwise-healthy patients, despite of the lack of an adequate operating room. The first attempt at an amputation took place under a mango tree with light provided by flashlights and the patient under intravenous general anesthesia. The patient died during the procedure. The second patient, an 18-year-old, required a right arm amputation. He survived.
The following morning, in bright daylight, after only a few hours of sleeping on tables or on the sidewalk, we decided to create an operating room, using some dividers and three dining tables. We had a fair number of useful surgical tools, but there was only one pulse oximeter and one blood-pressure cuff. Still, we performed two operations at the same time to take advantage of the daylight, since we had no other source of bright light.
On the first day, we performed eight amputations and three débridements. The improvised operating room functioned for 5 days, during which the team performed a total of 22 amputations and 68 other procedures. There was an improvised recovery area where a pediatric ICU nurse cared for the patients. There were no additional deaths during surgery or in the recovery room. This experience taught me the value of ketamine — the mainstay of our anesthetic management.
As jarring as these details may seem, all this was not entirely new to me. In medical school, I had encountered similar scenarios, though at the time I lacked the resources to help. Now, for the first time, with some limited supplies, I was able to truly help those under my care. For these patients, the small amount of antibiotics and intravenous fluids we brought made the difference between life and death.
Paul B. Delonnay, M.D.
Boston Medical Center
No potential conflict of interest relevant to this article was reported.
This article (10.1056/NEJMpv1001789) was published on February 19, 2010, at NEJM.org.