This is an extract from the diary of Dr. George Dyer (BWH)
At St Marc a town 90 min from PAP in what's considered a large regional hosp. It is totally overwhelmed by patients.
Team includes several you would know-- Malcolm Smith from MGH, Selwyn Rogers from BWH.
Things badly organized and chaotic when we arrived. While trying to be culturally sensitive we have essentially taken over like an invading army. For example OR had no functioning anesthesia machine though three broken ones. There are two OR rooms and a PACU by design but disuse and necessity had left one OR completely useless and PACU turned into disorganized storeroom. Remaining OR had been used essentially only for c-sections under IV general it seems. Spent first day cleaning and repairing and reorganizing. Now have 2 working rooms each with an anesthesia machine. PACU functional and now has monitors. Our hosts have been unfailingly gracious and work unbelievably hard for us--most accomplishments refining OR have been their work really.
Clinical situation is overwhelming to think about. Census of acute surgical patients ~ 150, which took 2 days of superhuman work by internist, ED MD and non-OR RNs to catalog and begin to prioritize. Every one of those cases is as bad an injury as we usally see in a week-- nearly every fracture is open and/or has associated untreated compartment syndrome. Some open fractures were closed dirty or even casted open in other hospitals before we arrived. Catalog includes open pelvis fractures grossly unstable, spine fractures with 6 quads and paras, and many many missed compartment fractures and open injuries. This whole country is made of concrete buildings and most of Port au Prince fell down with people inside. Terrifying to think about.
Have done 27 cases so far. Our only operations have been I&Ds, amputations and 2 ex-laps to save life. Through resourcefulness and sheer force of will Malcolm was able to obtain Ex-fixes yesterday by raiding warehouses and an underutilized hospital in Port au Prince--I'll let him tell the story-- but we will sadly mostly need saws for now. We triage and determine OR list by acuity trying to save lives, then limbs. No room to manage deformity or any such niceties. Though it feels to us like Schindler's List, we also find that many patients refuse amputation because in this culture and with hardship a part of normal-pre earthquake life there is little way for an amputee to support him or herself. A priority in coming months will be to recruit prosthetists and solicit donation of simple durable prosthetic limbs.
We are falling behind though. Strange that there is no history to take on any patient. Most are young and were perfectly healthy until their house fell on them on 1/12/10. Sadly there was a small second wave of injuries mid week from aftershock. No building fell but terrified people jumped from balconies after experience the week before. For the most part though it means that all injuries are the same age so they are marching through the natural history from a uniform starting point, their clinical course distinguished only by their health status and the particulars of their injuries. We are of course trying to record everything so that others may benefit from this horrific experience.
Among our newer challenges is to control and harness the flood of volunteers who have descended on Haiti to help. We feel priviliged to be part of a well-established organization with decades of credibility and history here. Others are coming out of the woodwork. These are having a harder time finding useful roles and I fear they're actually a net burden because they consume resources while doing little high-quality work.
We feel proud and priviliged to be working here and despite the horrible odds we are facing as people grow sicker each day we are hopeful because Haiti is clearly a nation of winners. Just to get by here even before the earthquake people had to be pretty resourceful and resilient. Now it is evident just how tough they really are.
Thanks to all of you for all you're doing while we're gone.
George.
Wednesday, January 27, 2010
Sunday, January 24, 2010
January 24 Update
This is an extract from the diary of Dr. Malcolm Smith (MGH)
"Thank-you everyone! We are all fine, although have had no time to text since yesterday.
Things here starting to work. We are coming off critical triage mode, but have masses of work to do, fixing dozens of people who have had very serious, but non life-threatening injuries, which we have not been able to deal with, while we were working full-time in life-saving mode. Much the same message coming from some other surgical units working here. It sound like surgically it's "game on", and docs beginning to put people back together. Those of us working at S Marc are now, essentially, starting to put people back together again. You can't imagine the
emotion this creates. Moral soared yesterday as patients were coming out of OR
fixed -- then we had 2 deaths during evening rounds, one a massive PE [blood clot in the lung] and another a medically sick baby. Heartbreaking. The reality of poverty and what's happened here hits you all over again when things like this happen.
We understand that the USS Comfort is working. Had contact and have heard evac helos flying overhead. We are hoping for our first evac today for their ICU, for a young woman with tetanus. None of us working here has ever seen case of tetanus before we began working here! The reinforcements that arrived here more than 24 hours ago are essentially enough to run hospital and teach local staff. Don't need more staff now that a second team from california organised by Partners in Health has arrived. We now have about 30 core people with some others co-opted in. Had major problem yesterday though, with arriving Docs etc in uncoordinated groups who want to work. One major lesson for me in all of this is that good will has to be organised to do good. So thankful for Partners in Health for the organizing they have done.
We are now doing cases with kit [orthopedic fixation equipment] sent by Synthes, and which I picked up in PoP day before yesterday, but we will run out by the end of today. Art Leary's Synthes/AO stuff [i.e. more orthopedic fixation equipment] for us has arrived, but it is stuck in the capital. I'm driving there now to get it, as contact time is set, by text message, for 8am. Contact time hopefully ok. Phones not working well today.
Port au Prince still sounds very bad. Damage there terrible. Here, at S Marc,
we found cracks in the tile in our OR Floor after the aftershock 2 days ago, and had to stop operating in that room. But it has now been checked by US structural engineers sent by Partners in Health, and all found to be OK. Decided on reflection that it is old damage, unrelated to earthquakes. Have some very basic skin graft equipment, but urgently need skin graft knife and blades. Electric dermatome best, as we have no air power and will need lots of big grafts. Old hand knife will be
difficult. Mark/Jnette can you help? Thank you for tourniquet: already saved life.
Country will need thousands of vacs. Can someone please talk to KCI? Coordination around this place is a nightmare.
We are now having problem with some of our very ill patients and their families. They have infected open fractures that are not reconstructable [i.e. they will die without surgery], but are refusing surgery,in case they require amputation. They are just frightened, because they know there is no limb fitting services in this country. Heard of same problem all over. Families take them away for second opinion which will be the same. The next phase of our efforts needs to be directed for limb fitting/prosthetics.
Any one who can help, please do!
James Toussiant joined us yesterday (our Haitian ortho resident). A gem of a guy solving many problems immediately, because he can communicatate brilliantly with our patients, not only because he speaks the language, but because he understands the culture. Still, our patients' fear of amputation and refusal of surgery is a real problem, despite his best efforts. Hoping to do 20 cases today in our two ORs, especailly now that we have enough staff to do dressings under sedation on wards!
The fact that we now have enough staff to offer kindness in care, as well as basic life saving, extremely important for the wellfare of our patients and their very worried families.
First wave of surgery expected to be done by saturday. We will then need a different team ortho/plastic surgery, nursing PT and lots of admin at this point, and all this needs to be organised carefully. Community will need lot of trained nurses. Specifically need loads of Haitian-American nurses and doctors to
bridge the gap. We feel so fortunate to have had some.
Thank-you all so much, everybody, for caring about these people, and spreading the word about the terrible things they are going through, and how much of our help they need. You can't imagine how much it means to all of us working here."
********************************************
From a recent, brief text to his wife, it is clear that Malcolm did, indeed, drive to Port-au-Prince this morning, was successful in picking up the Sythses kits, and is now back in S Marc. But his phone and text capacity is hardly working. These people need a satellite phone!
"Thank-you everyone! We are all fine, although have had no time to text since yesterday.
Things here starting to work. We are coming off critical triage mode, but have masses of work to do, fixing dozens of people who have had very serious, but non life-threatening injuries, which we have not been able to deal with, while we were working full-time in life-saving mode. Much the same message coming from some other surgical units working here. It sound like surgically it's "game on", and docs beginning to put people back together. Those of us working at S Marc are now, essentially, starting to put people back together again. You can't imagine the
emotion this creates. Moral soared yesterday as patients were coming out of OR
fixed -- then we had 2 deaths during evening rounds, one a massive PE [blood clot in the lung] and another a medically sick baby. Heartbreaking. The reality of poverty and what's happened here hits you all over again when things like this happen.
We understand that the USS Comfort is working. Had contact and have heard evac helos flying overhead. We are hoping for our first evac today for their ICU, for a young woman with tetanus. None of us working here has ever seen case of tetanus before we began working here! The reinforcements that arrived here more than 24 hours ago are essentially enough to run hospital and teach local staff. Don't need more staff now that a second team from california organised by Partners in Health has arrived. We now have about 30 core people with some others co-opted in. Had major problem yesterday though, with arriving Docs etc in uncoordinated groups who want to work. One major lesson for me in all of this is that good will has to be organised to do good. So thankful for Partners in Health for the organizing they have done.
We are now doing cases with kit [orthopedic fixation equipment] sent by Synthes, and which I picked up in PoP day before yesterday, but we will run out by the end of today. Art Leary's Synthes/AO stuff [i.e. more orthopedic fixation equipment] for us has arrived, but it is stuck in the capital. I'm driving there now to get it, as contact time is set, by text message, for 8am. Contact time hopefully ok. Phones not working well today.
Port au Prince still sounds very bad. Damage there terrible. Here, at S Marc,
we found cracks in the tile in our OR Floor after the aftershock 2 days ago, and had to stop operating in that room. But it has now been checked by US structural engineers sent by Partners in Health, and all found to be OK. Decided on reflection that it is old damage, unrelated to earthquakes. Have some very basic skin graft equipment, but urgently need skin graft knife and blades. Electric dermatome best, as we have no air power and will need lots of big grafts. Old hand knife will be
difficult. Mark/Jnette can you help? Thank you for tourniquet: already saved life.
Country will need thousands of vacs. Can someone please talk to KCI? Coordination around this place is a nightmare.
We are now having problem with some of our very ill patients and their families. They have infected open fractures that are not reconstructable [i.e. they will die without surgery], but are refusing surgery,in case they require amputation. They are just frightened, because they know there is no limb fitting services in this country. Heard of same problem all over. Families take them away for second opinion which will be the same. The next phase of our efforts needs to be directed for limb fitting/prosthetics.
Any one who can help, please do!
James Toussiant joined us yesterday (our Haitian ortho resident). A gem of a guy solving many problems immediately, because he can communicatate brilliantly with our patients, not only because he speaks the language, but because he understands the culture. Still, our patients' fear of amputation and refusal of surgery is a real problem, despite his best efforts. Hoping to do 20 cases today in our two ORs, especailly now that we have enough staff to do dressings under sedation on wards!
The fact that we now have enough staff to offer kindness in care, as well as basic life saving, extremely important for the wellfare of our patients and their very worried families.
First wave of surgery expected to be done by saturday. We will then need a different team ortho/plastic surgery, nursing PT and lots of admin at this point, and all this needs to be organised carefully. Community will need lot of trained nurses. Specifically need loads of Haitian-American nurses and doctors to
bridge the gap. We feel so fortunate to have had some.
Thank-you all so much, everybody, for caring about these people, and spreading the word about the terrible things they are going through, and how much of our help they need. You can't imagine how much it means to all of us working here."
********************************************
From a recent, brief text to his wife, it is clear that Malcolm did, indeed, drive to Port-au-Prince this morning, was successful in picking up the Sythses kits, and is now back in S Marc. But his phone and text capacity is hardly working. These people need a satellite phone!
January 23 Update
This is an extract from the diary of Dr. Malcolm Smith (MGH)
"Major changes by the minute. Good U.S. staff here now at St Marcs, with Partners in Health reinforcements. Medical supplies are beginning to arrive, and we have contact with the hospital ship Comfort. We may get helicopter to transfer most need patients. Still many here need surgery, but no more deaths today. Now worrying over future, long-term care, so necessary for many of our patients."
"Major changes by the minute. Good U.S. staff here now at St Marcs, with Partners in Health reinforcements. Medical supplies are beginning to arrive, and we have contact with the hospital ship Comfort. We may get helicopter to transfer most need patients. Still many here need surgery, but no more deaths today. Now worrying over future, long-term care, so necessary for many of our patients."
January 22 Update
This is an extract from the diary of Dr. Malcolm Smith (MGH)
Dear everyone,
It’s been another hard day in Haiti. There is some good news, but the situation continues to be very precarious, indeed, it is more precarious each day, and although many people are working really hard on their behalf to get them support and supplies, the only organization that has managed to get anything through is Partners in Health. Partners in Health is keeping them up and running, but they are hanging on by their fingernails, but are in desperate need of other support as well, particularly having to do with supply and logistics.
Here are some of Malc’s texts from yesterday:
First thing in the morning: “In car, going to get kit [i.e., medical supplies at the airport in Port-au-Prince]. Team working really well.”
Noon: “Made it to PoP. Running out of antiseptic drugs at hospital, but just found a box from Brigham and Women’s, full enough to work for more than a week… gold dust.”
4:15. “Spoke to U.S. Ranger on way out of town, and he said only minimal trouble.”
And from 1:35 am this morning: “Late day, but we are all ok. Infections and complications starting to kill people.
And from 1:30 p.m. this afternoon: “Been too busy to contact. Please pass on the following: went to capital yesterday to raid essential supplies. Was successful, but complete confusion there––major problems with multiple teams having to work out policies. We have it much better as a group here in St Marc. Came back happy, but happiness didn’t last long, because 5 patients had died and moral had really dipped. Team, though pulling together and working.
Saw lots of confusion in Port-au-Prince. Clear that non coordinated aid is worse than no aid as it blocks very limited transport resources. Logistics essential with coordination. Have ortho supplies just for us on a Synthes [the maker of these supplies] private jet loaded and ready to leave with landing time set with military ATC for this evening. Thank you Art Leary! Love any help we can get with this. Medical situation here and in capital worsening as infected patients die. The hospital ship is now here, but no news on how to transfer our patients.
We will soon need co-ordinated surgical supply, but planning for restocking very difficult as country has no distribution network. Partners in Health have been very good at helping, and have 2 reps at airport to meet the Synthes plane currently. Anyone who can offer help needs to be coordinated through them, but situation changes by the minute. Much more numerical need in capital, and from visit clear that if/when cholera hits thousands will die. But surgical risks same here at St Marc as in capital, with numbers of cases outstripping resources. Worried that we will get COMPLETELY stopped by something we have not thought about.”
Dear everyone,
It’s been another hard day in Haiti. There is some good news, but the situation continues to be very precarious, indeed, it is more precarious each day, and although many people are working really hard on their behalf to get them support and supplies, the only organization that has managed to get anything through is Partners in Health. Partners in Health is keeping them up and running, but they are hanging on by their fingernails, but are in desperate need of other support as well, particularly having to do with supply and logistics.
Here are some of Malc’s texts from yesterday:
First thing in the morning: “In car, going to get kit [i.e., medical supplies at the airport in Port-au-Prince]. Team working really well.”
Noon: “Made it to PoP. Running out of antiseptic drugs at hospital, but just found a box from Brigham and Women’s, full enough to work for more than a week… gold dust.”
4:15. “Spoke to U.S. Ranger on way out of town, and he said only minimal trouble.”
And from 1:35 am this morning: “Late day, but we are all ok. Infections and complications starting to kill people.
And from 1:30 p.m. this afternoon: “Been too busy to contact. Please pass on the following: went to capital yesterday to raid essential supplies. Was successful, but complete confusion there––major problems with multiple teams having to work out policies. We have it much better as a group here in St Marc. Came back happy, but happiness didn’t last long, because 5 patients had died and moral had really dipped. Team, though pulling together and working.
Saw lots of confusion in Port-au-Prince. Clear that non coordinated aid is worse than no aid as it blocks very limited transport resources. Logistics essential with coordination. Have ortho supplies just for us on a Synthes [the maker of these supplies] private jet loaded and ready to leave with landing time set with military ATC for this evening. Thank you Art Leary! Love any help we can get with this. Medical situation here and in capital worsening as infected patients die. The hospital ship is now here, but no news on how to transfer our patients.
We will soon need co-ordinated surgical supply, but planning for restocking very difficult as country has no distribution network. Partners in Health have been very good at helping, and have 2 reps at airport to meet the Synthes plane currently. Anyone who can offer help needs to be coordinated through them, but situation changes by the minute. Much more numerical need in capital, and from visit clear that if/when cholera hits thousands will die. But surgical risks same here at St Marc as in capital, with numbers of cases outstripping resources. Worried that we will get COMPLETELY stopped by something we have not thought about.”
Saturday, January 23, 2010
This is an extract from the diary of Dr. Malcolm Smith (MGH)
Went to capital yesterday to raid essential supplies. Was successful but complete confusion, major problems with multiple teams having to work out policies. We have it much better as a group here came back happy. Got back to find 5 pts had died and moral dipped, team pulling together and working. Saw lots of confusion in Port au Prince, clear that non coordinated aid is worse than no aid as it blocks very limited transport resources. Logistics essential with coordination. Have ortho supplies just for us on synthes private jet loaded and ready to leave with landing time set with military ATC for this evening thank you art leary. Love any help situation here and in capital worsening as infected patients die. The ship is here but no news of transfers Will need co-ordinated surgical supply but planning for restocking very difficult as country has no distribution network. PIH have been very good at helping have 2 reps at airport to meet plane currently any help has to be coordinated through them but situation changes by the minute. Much more numerical need in capital and from visit clear that if/when cholera hits thousands will die. But surgical risks same here with numbers of cases outstripping resources worried that we will get Completely stopped by something we have not thought about
Went to capital yesterday to raid essential supplies. Was successful but complete confusion, major problems with multiple teams having to work out policies. We have it much better as a group here came back happy. Got back to find 5 pts had died and moral dipped, team pulling together and working. Saw lots of confusion in Port au Prince, clear that non coordinated aid is worse than no aid as it blocks very limited transport resources. Logistics essential with coordination. Have ortho supplies just for us on synthes private jet loaded and ready to leave with landing time set with military ATC for this evening thank you art leary. Love any help situation here and in capital worsening as infected patients die. The ship is here but no news of transfers Will need co-ordinated surgical supply but planning for restocking very difficult as country has no distribution network. PIH have been very good at helping have 2 reps at airport to meet plane currently any help has to be coordinated through them but situation changes by the minute. Much more numerical need in capital and from visit clear that if/when cholera hits thousands will die. But surgical risks same here with numbers of cases outstripping resources worried that we will get Completely stopped by something we have not thought about
Friday, January 22, 2010
January 21st Update
This is an extract from the diary of Dr. Malcolm Smith (MGH)
Will try tomorrow. Late day but we are all ok, infections and complications are starting to kill people.
Will try tomorrow. Late day but we are all ok, infections and complications are starting to kill people.
Thursday, January 21, 2010
January 20th Update
This is an extract from the diary of Dr. Malcolm Smith (MGH)
Wednesday 1/20 St Marc Haiti
As you will know we woke to another earthquake this morning, it was a bit frightening. We were just waking and all ran outside but only felt a short tremor and no damage. Makes you feel so sorry for the people here there was clearly nothing they could do. Later in day had more patients after people jumped off buildings in fear of being trapped. Now have both rooms running at last as Akshay arrived after being stuck in Port au Prince. Even managed to bring his supplies with him, we have clean scrubs!
Did 6 more cases same problems, debride or amputate. The wounds much worse than first impression when you get them to surgery with lots of dead tissue and now with spreading infection. All have fragments of grit and grey concrete dust everywhere. All now over a week old and if open are now infected. Compartment syndromes were all too late when we arrived but judged to leave them if closed and distal pulse although all had no distal motor function.
Still working in full disaster triage mode as critical casualties overwhelm resources which creates difficult decisions. As yet have no resources to
evacuate and still have open wounds to treat
Triage scheme
A - urgent surgery for life today
B - urgent surgery for limb today
C - urgent surgery for wounds not yet life threatening can wait
D - OR care for closed fx MUA or surgery if pos (ex fix)
E - evacuate
F - observe
Today have waiting in house
8 closed pelvic ring most C types
1 open pelvic ring - big VS
6+ week old compartment syndromes they have got distal pulses but no foot /arm
function also sent several away to return later
21 Complex open fx +(22 done)
5 paraplegic/quadriplegic
21 adult closed femur
4 paed femur
2 complete open femoral epiphyseal fractures and 2 children and i 2 and 8 year
old
2 complex open knees/ tibia in 2yr old
I bad open tibia 2 year old
Lots of wounds in house and in ED
And 3 more C section babies today
Our nurses have sorted the rooms and are now working with the Haitian nurses
(who are doing great) established new patient charts and dressing stations in
each "ward". Have regular vital signs rounds and educating about rhabdo and
wound care. Very grateful for support from home outstanding from too many people
to mention.
Managed to talk to Robert Primus - thank you - who is Congressman Michael E.
Capuano's chief of staff in DC this morning. They are hoping to help with air
support for supplies as have soccer field only 5 mins from hospital, sounds
wonderful!
Malcolm
Wednesday 1/20 St Marc Haiti
As you will know we woke to another earthquake this morning, it was a bit frightening. We were just waking and all ran outside but only felt a short tremor and no damage. Makes you feel so sorry for the people here there was clearly nothing they could do. Later in day had more patients after people jumped off buildings in fear of being trapped. Now have both rooms running at last as Akshay arrived after being stuck in Port au Prince. Even managed to bring his supplies with him, we have clean scrubs!
Did 6 more cases same problems, debride or amputate. The wounds much worse than first impression when you get them to surgery with lots of dead tissue and now with spreading infection. All have fragments of grit and grey concrete dust everywhere. All now over a week old and if open are now infected. Compartment syndromes were all too late when we arrived but judged to leave them if closed and distal pulse although all had no distal motor function.
Still working in full disaster triage mode as critical casualties overwhelm resources which creates difficult decisions. As yet have no resources to
evacuate and still have open wounds to treat
Triage scheme
A - urgent surgery for life today
B - urgent surgery for limb today
C - urgent surgery for wounds not yet life threatening can wait
D - OR care for closed fx MUA or surgery if pos (ex fix)
E - evacuate
F - observe
Today have waiting in house
8 closed pelvic ring most C types
1 open pelvic ring - big VS
6+ week old compartment syndromes they have got distal pulses but no foot /arm
function also sent several away to return later
21 Complex open fx +(22 done)
5 paraplegic/quadriplegic
21 adult closed femur
4 paed femur
2 complete open femoral epiphyseal fractures and 2 children and i 2 and 8 year
old
2 complex open knees/ tibia in 2yr old
I bad open tibia 2 year old
Lots of wounds in house and in ED
And 3 more C section babies today
Our nurses have sorted the rooms and are now working with the Haitian nurses
(who are doing great) established new patient charts and dressing stations in
each "ward". Have regular vital signs rounds and educating about rhabdo and
wound care. Very grateful for support from home outstanding from too many people
to mention.
Managed to talk to Robert Primus - thank you - who is Congressman Michael E.
Capuano's chief of staff in DC this morning. They are hoping to help with air
support for supplies as have soccer field only 5 mins from hospital, sounds
wonderful!
Malcolm
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