Sometimes a Utility Knife (and Knowing How to Use It) is Better than a Scalpel

My update today is inspired by the email attached below, written by the leader of a highly skilled surgical team. With the best intentions he went to help in Haiti, but lacked critical elements for a successful mission.

In 18 years of disaster relief work, both national and international, I have seen everything from medical students walking on the World Trade Center rubble pile at 9/11 wearing sneakers and scrubs (lacking proper protective clothing) and a backpack filled with first aid supplies, to well-organized, financed, and politically connected teams like the one described below who, while well intentioned, are operating “rogue” and outside the established disaster response process.  While well intentioned, they can either fail to accomplish their mission, or worse, can become a liability to the response process, putting themselves and others at risk.

This team’s experience reminds me that this work is neither for the faint of heart, nor for the inexperienced.  Their failure to have team leadership from an experienced international emergency responder led to a cascade of critical failures including but not limited to:

  • Proper planning for security, resupply, or provision of basic necessities to deliver care;
  • A failure to integrate with the existing disaster management process (which they apparently never found even though it exists);  and
  • A miscalculation that sophisticated Western medical care can simply be brought to such a chaotic and austere environment and immediately be supported.

There are many lessons in the experiences of the team described below that go beyond what the author shares.  I personally disagree with the conclusion drawn by the author in his statement toward the end:  “Our role now being back in NY is to expose the inadequacies of the system to the media in the hopes of effecting a change in this system immediatly [sic].”  I think the the more important lesson in his team’s experience is that anyone or any team interested in volunteering to participate in such complex humanitarian disasters should do so with organizations who make it their business to respond to these events.  Well-intentioned efforts, even when well funded and with ‘political connections, risk mission failure or worse when they lack experienced disaster response leadership and logistical support.

—–Original Message—–
Date: Thu, 21 Jan 2010 00:11:38
Subject: Re: Haiti

I believe we went in with a reasonably comprehensive service we wanted to provide acute trauma care in an orthopedic disaster. Our plan was to be at a hospital where we could utilize our abilities as trauma surgeons treat the acute injuries involved in an orthopaedic disaster. We expected many amputations however came with a philosophy that would reasonably start limb salvage in what we thought was a salvageable limb.

David Helfet put a team together which included:
2 orthopaedic trauma surgeons
3 orthopaedic trauma fellows
2 highly skilled anesthiologists
1 general surgery trauma surgeon
2 synthes reps who were also scrub techs
1 trauma nurse practioner to do triage
2 OR nurses

Our equipment including a huge amount of anesth medications and equipment, ability to construct 150 ex fix both small and large, OR equipment including scalpels etc, OR soft goods, splint material, OR prep material.

We also had a plan of physician and equipment replacemnt that was dynamic where w/i 24hrs we could bring in what was necessary on the Synthes private jet.

We thought the plan was a good one.

We were incredibly naïve.

Disaster management on the ground was nonexistent. The difficulties in getting in despite the intelligence we had from people on the ground and david helfet’s high political connections with Partner’s in Health as well as the Clintons only portended the difficulties we would have once we arrived.

We started out friday morning, got a slot to get in friday that was eventually cancelled when we were on the runway to be rescheduled the next day. We diverted to the DR and planned on arriving in P OP saturday.

Once on the ground the hospital we had intelligence that was up and running with 2 OR’s General Hospital was included severely in the earthquake and not capable of running functioning OR’s as there was no running water and only a limited electrical supply on generator.

We quickly took our second option
Community Hospital of Haiti. We found approx 750 pt in the hospital upon our initial eval, the hospital had running water, electricity and 2 functional OR’s

Our naivette did not expect that the 2 anesth machines would not work, there would be 1 cautery for the hospital, autoclave that fit instruments the size of a cigar box, no sterile saline, no functioning fluoro and no local staff only a ragtag group of voluntary health providers who like us had made it there on there own.

To summarize we had no clue the medical infrastructure of the country was so poor.

As we got up and running in the OR and organized the patients for surgery we communicated our new needs back to Synthes and more supplies were loaded for a second trip – these included battery operated pulse lavage, a huge supply of saline, soft goods in the OR. This plane landed as planned sunday pm, equipment was loaded on a truck and subsequent hijacked between the airport and the hospital.

At the hospital we had zero security despite promises form NYPD and NYFD to provide that to us.

Our philosophy was to work like this was a marathon run the OR’s around the clock with the idea that we would have a defined extraction time of 11pm tues. The plane that extracted us would come in with a new medical staff compliment to replace us. Equipment included urgent things to maximize issues that were nonexistent in the hospital that would enable us to provide better and more efficient care:
2 portable anesth machines
2 electrocautery
2 portable monitors for the pacu
2 autoclaves
Replacement exfix
Things that didn’t arrive with the previous flight

That plane’s slot was cancelled by the military at 6am tues.
We also previously had seen daylight in the remaining patients monday night haviving completed approx 100 surgeries. However on tues morning we found a huge # of new patients. The hospital was forced to undergo lockdown closing its gates to the outside and outside crowd becoming angry.

We also noted tues morning that many of the patients we were operating on were becoming septic.
We finished operating at noon tues, the last surgery our group assisting an obstetrician on a caesarian and resuscitating a baby that was not breathing.

We decided as a group the situation for us at the hospital was untenable as supplies were running out, team was exhauted, safety a huge concern, and no extraction plan with resupply. We decided to make our way to airport thru the help of a hospital benefactor. Jamaican soldiers with M-16s were necessary to escort us out with our luggage as the crowd outside saw us abandoning the hospital.

We made it to airport on back of a pickup track, got onto the tarmac, hailed a commercial plane that carried cargo to montreal and had private jet pick us up there.

The issues we were unprepared for and witnessed were
1. The amount of human devastation
2. The complete lack of a medical infrastructure in the country
3. The lack of support of the haitian medical community
4. The complete lack of any organization on the ground. No one was in charge, we had the first functional up and running hospital in the P OP area yet no one and I me NO ONE came to the hospital to assess what we were doing, what we were capable of doing and what we would need, to be more efficient. The fact that the military could not or would not protect the resupply equipment on sunday or let the tues flight come in says it all.
5. Lack of any security at all at the hospital

I would take away that disasters like this need organization on a much higher level than we had with the clear involvement and approval of the military from the beginning.

Currently there is No one obviously running the show and care is in chaotic at best. MDs are coming in country with no plan of what the are going to do. Surgeons that expect to just show up and operate are delusional as to what there role would be as without a complement of support staff and supplies they would be of limited or no value.

I hope this helps. We all felt as though we abandoned these patients and that country and feel terrible. Our role now being back in NY is to expose the inadequacies of the system to the media in the hopes of effecting a change in this system immediatly. We feel that the only way to really help now is an urgent programtic change and organization in the support of the medical staff on the ground and what is critically needed to expeditiosly bring in.

Cherrios on the tarmac are not getting it done on these patients which clearly would be savable if good care could urgently be provided.

Please share this email with everyone and anyone you find might help.

Good luck

Dean

Update from Hernando Garzon, MD, January 28, 2010.

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4 responses to “Sometimes a Utility Knife (and Knowing How to Use It) is Better than a Scalpel

  1. A very disturbing email to say the least, but that is the unfortunate reality of 3rd world countries. We must, as the leader of the free world, come together with fellow caregivers and make a chg for the better. Where we start is here in our own homes, neighborhoods, places of worship ( regardless of faith ). We must fight for the voiceless and oppressed around the globe. May peace be with each of you!

  2. As a layman, I read the information about Haiti, and realized the magnitude of the problem there. For a group of medical professionals to travel to Haiti without any understanding of the conditions is rather sad.

    Nice of them to bring that sophisticated equipment, but they were in a 3rd world country devastated by an earthquake. What part of “earthquake” didn’t they understand?

    I applaud their efforts, but notice they were expecting other professionals to contact them. (When in Rome, do as the Romans do.)

    In reading the blog from Suzi Fitzgerald, I realized she knew what she was getting into.

  3. Amazed (but not really) at the audacity of this team that think that money and political connections will get you everywhere. The gods, oh I mean doctors are coming in to fix everything!! Their hearts were in the right place but they were extremely unrealistic. There role now is to “uncover the inadequecies of the system to the media” Really?! The media is going to help? Again, unrealistic expectations. This is a country that was moving themselves from misery to poverty before the quake hit. What kind of infrastructure did they expect?? The blame they place sounds offensive and very entitled, as if they were trying to work around the system instead of within it.

  4. too bad they did not contact those of us that have been in such situations and know the score as to what is needed both from a logistical standpoint and medical standpoint. It would behoove Kaiser to identify and make such human resources available so that the next major disaster Kaiser medical personnel could benefit

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