Vivian Reyes, MD, Offers Disaster Readiness Tips Steeped in Her Time in Haiti

After leaving Haiti and returning to my life in the Bay Area, I felt as if I returned to another world.  The orderly rows of lights as I descended into Miami airport were a stark contrast to the haphazard state of Port-au-Prince.  There are few similarities between the scene I left and to that which I returned.  But, what if the same tragedy happened in our own country?  I learned many lessons during my five-week mission to Haiti, and will share a few of them here so that we can be better prepared to respond to future events on our own soil.

We have all heard the statement, “Communication is always the biggest problem during a disaster.”  In retrospect, I never truly understood the implications of this statement until now.  When I arrived in Haiti, local phone coverage was intermittent, at best.  Even when calls went through, the reception was often so bad that it was more frustrating than helpful.  Satellite phones were unreliable and generally unusable.  Surprisingly, my iPhone seemed to send and receive text messages and email without much problem.  While this was good for simple communications, texting proved too time-consuming, and time was not a luxury that I had.  Coordinating relief operations via any electronic means proved to be difficult, and face-to-face communication became invaluable. As a lesson learned, I would urge everyone to become adept at text messaging so that you are better prepared for times when communication is limited.  I heard many stories of trapped victims texting their friends and family; through this communication alone victims were rescued.

Although helpful, the time delay and content limits of text messages made me realize how important it is to be self-sufficient and decisive during the aftermath of a disaster.  “Be prepared,” is another commonly heard statement in disaster readiness.  Before I left for Haiti, I read a book by Amanda Ripley, called “The Unthinkable, Who Survives When Disaster Strikes – and Why”.  She describes human response to disasters and discusses ways in which we can react better to such situations.  The author believes that the people around you during a disaster are the critical component to whether you survive it.  In Haiti, several days passed before international aid arrived.  Before then, the Haitians could rely only on those around them.  Preparation makes a difference not only in how effective the response is, but ultimately in how many lives are saved.  As a lesson learned, each and every one of us should think of how we will help our neighbors during a disaster.  The more times you run through scenarios in your mind or in a drill, the better you will react in a real event.  Now when you hear “Be prepared,” don’t just consider the supplies you might need, but also think of what role you will play in the hours or days after a disaster…without communication.

The next lesson is one that became a hot topic after Hurricane Katrina:  “Crisis care guidelines,” which was previously called “crisis standards of care” or “alternate standards of care.”  During the management of disasters, resources are limited, and patients will not be able to get the same quality of care that they would get during an average, non-disaster-stricken time.  Crisis care guidelines were developed to help medical professionals navigate through these difficult times.  For instance, if there are too few ventilators for patients who require one, which patients get the ventilators?  Similarly, mass casualty triage is another form of crisis care management.  In Haiti, the baseline country standard of care was generally not to intubate critically ill patients.  As disaster responders it is imperative that we have a grasp of the current standards of care.

What also became apparent is that these standards change rapidly depending on the resources available.  For instance, when the German Red Cross set up a tent hospital 15 minutes away from our clinic with ventilator and ICU capability, our clinic’s standards of care changed.  Similarly, when the hospitals around us filled up and stopped taking critically ill patients, our standards changed.  This occurred day by day, and sometimes hour by hour.  This accentuated the fluid nature of disaster work, and is something that should be considered when we consider crisis care guidelines in our own hospitals and within our own communities.

The last lesson I will address is that of organization.  In a previous blog, I mentioned the chaos in Haiti during the emergency response.  This is not unique to Haiti, and is expected after any catastrophic event.  While I seem to thrive in chaotic environments, I also recognize the importance of trying to minimize chaos to improve efficiency and productivity.  During visits to several different hospitals in Port-au-Prince, I witnessed American physicians, nurses, and medical support volunteers arriving unannounced and offering their expertise.  Similarly, many donors sent large quantities of supplies to various hospitals in Haiti.  While these gestures are very much appreciated, the proper coordination of these activities would allow for better productivity of volunteer medical staff and better management and use of supplies.  Similarly, better coordination would allow for better safety, security, and planning.  The lesson learned from this is that if anyone is interested in participating in future disaster efforts, signing up now to be a health care volunteer is the best approach.  You may do this through your hospital, (available to any Kaiser Permanente employee nationally), your county or state professional associations, or various non-governmental organizations.  If you wish to donate money or supplies to future relief efforts, donate to organizations that you trust now so that they can appropriately coordinate their efforts and be prepared and ready for the next disaster. If everyone followed these simple steps, I am convinced that the level of chaos would be more manageable and the efficiency of response efforts would improve.

The people of Haiti may seem like they live in a different world, but as Amanda Ripley describes in her book, “Fear is a primitive response.”  Humans, no matter where they are, will have the same fear response.  If we stand ready for disaster, we will fear it less, and we will come together and manage it.  Let us learn from this tragedy and prepare ourselves, so that this historic tragedy will not repeat itself.

Thanks for taking the time to read my blogs, and most importantly, thank you for your tremendous support.

Vivian Reyes, MD
Relief International
Kaiser Permanente San Francisco Medical Center

Relief International Video Shows Kaiser Permanente Doctors Working in First Few Days After the Quake

The following video was made by Chip Duncan, a film maker and member of the Relief International Board of Directors, who was in Haiti with our team in the early weeks of the Haiti earthquake emergency response. The video footage is largely of Kaiser Permanente doctors working in the clinic in the early days after the event. This brief video says more than many written updates. I hope that it gives you a sense of the work that was done in those first few weeks after the earthquake. 

‘Dr. Deb’ Recalls Her Work in Carrefour

Dispatch from Carrefour, 2/26/10

As I get ready to leave Haiti, I want to write for the first time.  Before this, I have felt unwilling to talk or write very much about what is happening here.  The immensity of the disaster makes words seem trivial.

First, I’d like to describe the daily routine of our Relief International team. We can hear (among the barking dogs and crowing roosters) people lining up as early as 3:30 a.m. for the clinic. There is a soft murmuring outside the wall of our compound, and an occasional baby crying. We get up between 5:30 and 6:30 and have a wonderful breakfast of Haitian coffee, hard-boiled eggs, and fresh fruit, and every other day we also had some oatmeal with cinnamon. We sit for a few minutes and then get ready for clinic, which begins at 8.

Yesterday morning, our routine was interrupted at 7:15 a.m. by a mother carrying her unresponsive 4-year-old son to our gates.  One of the security guards rushed her in and the docs and nurses started working, along with our cook, Guerline, who acted as translator.  We got the history that this child had had a seizure 2 hours previously and our fabulous ED nurses got an IV started and discovered his blood sugar of 41 (low) within minutes. He was immediately arousable after IV glucose and was swiftly packed into one of our cars (transport to a local hospital had been arranged during resuscitation).

 We then got back to readying the grounds and our tents for morning clinic. At 8 a.m. a few of the nurses and MDs “walked the line” to number the patients according to the acuity of their illness. The rest are taken in order. The rest of our day was relatively quiet with one mobile clinic going to Grassier while the “fixed” clinic continued to operate.

The Grassier site was in the courtyard of a school that was heavily damaged in the earthquake, while some children were in attendance. We sat under the trees with the breeze blowing off the ocean while we saw our patients.  I asked a lot of patients to tell me about what happened to them during the earthquake. We are seeing a huge amount of post-traumatic stress disorder. The mother of a 5-year-old girl who had scratched herself to the point of bleeding from head to toe, told me that the girl’s  twin brother had died. The team has seen suspected malaria, pneumonia, pyelonephritis, lots of diarrheal illnesses, malnourishment and a variety of problems related to a lack of chronic care for hypertension, diabetes, seizures, etc. I have spoken to parents who are starving themselves out of their feeling of responsibility to feed their children.

 The clinics run smoothly from morning through afternoon, even though the humidity has everyone running for water breaks – they’re never enough. Most don’t take adequate time to drink and there have been several episodes of dehydration among staff members. The late afternoon can be used for resting, or, more recently, emailing and calling from our “dining room table” since an NGO called NetHope came and installed these services for us.  They even work most of the time, depending on the available of city power or our generator. We wash our clothes, haul water  from the cistern into the bathrooms for bucket baths and toilet flushing,  stock the tents and chat. Sometimes a few of the team members help Guerline prepare dinner in the kitchen. Cooking is done over a small propane stove, or over charcoal. The suppers are very tasty and consist of Haitian rice and beans, or spaghetti, often with a chicken or vegetable stew.

The cohesiveness of our team is the best of any of the medical mission teams with which I have worked. After dinner, we have lots to do. We wash dishes, clean up and collect ourselves around the table for pill counting to restock for the next day’s mobile and fixed clinics. We pack the mobile clinic duffel bag and some of us work on guidelines for malnutrition, commonly encountered local clinical conditions, and nursing guidelines for incoming staff — RI or national. For me, it’s 10:30- 11 p.m. by the time I finally crawl into my “bug hut” and end my day.

The days have been busy and instructive, heat notwithstanding.  I love working with the Haitians. The people are courageous and gracious. The team has helped me look after my broken foot (from a hiking accident two days before I left for Haiti). I was given an ACE wrap and lots of instruction to keep my foot elevated (forget about ice!), which of course I did not do. I’m moving pretty quickly now.

The young Haitian men who serve as the primary source for our drivers, translators and security are very willing to talk about the situation here. They are sensitive and very protective of us. I hope Americans know that we are seen as a source of hope for the Haitian people. As Garry, a translator, said to me yesterday: “For Haitians, first God, then the U.S.”


Debra Cohen, MD, aka “Dr. Deb”
Pediatric Endocrinology
Kaiser Permanente Santa Clara Medical Center

Vivian Reyes, MD, Salutes the Unsung Heroes of Haitian Relief Efforts

Over the past few days, I have had the fortune of interviewing Haitian doctors and nurses to work in Relief International’s fixed and mobile clinics.  I have been surprised to see applicants with their papers in order, their clothes pressed and much cleaner than my own, and enthusiastic to provide care to their people in such a time of need.  After all that they have gone through and all that they have lost in the last month and a half, they are back on their feet and ready to work.  As I get ready to return home, I can see that, clearly, these are the true heroes in the Haiti relief effort. 

International relief workers often get credited for being the heroes in the wake of disaster. However, there are many unrecognized heroes in the Haiti relief effort.  These heroes are the survivors of the earthquake.  They are the Haitians who physically brought their neighbors to safety when they otherwise would have stood frozen with fear during the earthquake.  They are the ones who saved lives by digging out friends and family who were trapped immediately after the earthquake, and the ones who provided medical aid in the first few days after the earthquake, when international aid had not yet arrived.  The heroes are those who took in children orphaned by the quake, and those who brought food to victims that were too injured to get food themselves. They are the ones who comfort their neighbors during each aftershock that unnerves the nation.  The heroes are members of Relief International’s Haitian staff, who have worked every day without a break since the earthquake because their people need them.  I meet each of these heroes every day here.  After weeks, months, or years, relief workers will leave Haiti and return to their intact homes. But the Haitian survivors will continue, working hard to rebuild their country for generations to come. 

Other unrecognized heroes of the disaster relief efforts are the people at home, who fill the gaps while relief workers flee to the field.  They are our co-workers who fill in for our shifts and work duties in a moment’s notice.  They are our families who give us the support and courage to do this kind of work.  The heroes are also the millions of people who donate supplies and money so that such relief efforts are possible.

These are the true heroes, and I am grateful for them.  So, as I get ready to leave I want to recognize them and give them the credit they are due.  The Relief International team thanks you.

Vivian Reyes, MD

Kaiser Permanente San Francisco Medical Center

An OB-GYN Returns from Haiti, Ready to Go Back

  It’s great to be back in the land of hot showers,  but I came home too soon and will go back later this year when I can.  I left with a sense that I could have done much more,  had I stayed at least a week or two more, as I was just getting into the swing of things.  I became used to electricity failures,  no running water,  bucket baths (stand in the shower with a 5-gallon bucket of water,  pour cups of it over yourself,  wash,  rinse) and a limited menu (lots of spaghetti,  rice and beans).

We lived in a house in Carrefour, a red zone where the UN did not venture (too dangerous).  We saw patients in medical tents on the grounds of a house behind walls and a gate. The house is owned by an American doc from Wisconsin who has lived in Haiti for more than 30 years with her partner, a nurse.  They were moving to a town in western Haiti before the quake to start a clinic and they continued that process after the quake. They rented their house to  Relief International (the group I went with) and we’ll be there for some time until,  eventually,  a base clinic can be found/built.  Our group ranged between 12 to 20, with nurses and docs from the United States coming and going at different times.  Sleeping bags and mosquito nets were the rule.  I saw men, women and children with medical complaints.  I didn’t see much gyn stuff,  really — many cases of vaginitis that actually were not — but I did see some pregnant women and delivered three babies. Two were delivered at a hospital that we formed a loose affiliation with a few miles away and one that barely made it to a Doctors Without Borders hospital nearby.  That was wild: walked in, our group of patient, paramedic, translator and I were pointed in a direction where the delivery area was, found it, asked if there were a doc or midwife (none came) so I did the delivery, beautiful baby girl, smiles all around, and left. Where else on earth could an unknown doc walk into a barely staffed hospital, deliver an unknown patient, and walk out without anyone asking what’s up? If we hadn’t made it to the hospital that baby would have been born in one of our medical tents, perhaps tent one, the fertility tent, where a dog with her new puppies had established herself.

We also went to a couple of sites where we did mobile clinics, usually areas near tent cities where there were no other non-government organizations like our. We’d pitch our medical tent, see patients until we had to leave and do something similar in another location the next day.  We had a curfew of 6:30 meaning that if we were outside our compound we had to be in it again by 6:30 p.m.  The UN had been called to Haiti in 2004 since the government was ineffective at curbing random gang violence that was terrorizing Port au Prince and they’ve been there since. The head of the UN mission in Haiti was killed in the quake, along with other UN peacekeepers.  It was they who established the curfew and our group followed it;  others did not. The first few days I was there we would walk outside the compound a block or so in either direction.  Our translators and drivers come from the neighborhood and a couple were raised in an orphanage not far that was badly damaged and they were our guides.  One translator’s house collapsed completely; the family escaped but lost everything.  A neighbor family escaped,  all but a 2-month-old baby still under the rubble.  The building next to the orphanage collapsed with 13 people inside and the smaller children were afraid of their ghosts and refused to go near the orphanage buildings;  they lived in school buildings and tents just down the hill.  Many stories like that.  Our outside walks stopped when it was learned that we had become targets for kidnapping given our regular schedules.  So, we only left in SUVs and generally in a convoy with at least 2 vehicles.  I never felt unsafe,  though,  and am not sure about the kidnapping thing,  though that was happening before the UN came.

Much destruction all around,  everywhere you look.  People are living in tents even if their houses are standing, fearing collapse in another tremor.  I felt at least four aftershocks, all minor and similar to the little quakes we have here all along.  A couple were strong enough to send some of our group fleeing outside and produce screaming from the tent encampment next door, along with lots of dog barking and rooster crowing.  Roosters and dogs seemed to be everywhere and set up random racket through the night,  leading to  sleepless nights sometimes.  I slept in the building among the boxes of bandages and supplies. Most slept in tents in the yard and experienced rooster songs near their heads.

The Haitian people have endured so much for so long that this latest calamity is only one of a long string, though certainly the worst in history. We hear numbers like 220,000 dead, as many injured, a million homeless, 70 percent of schools destroyed, numbers that are incomprehensible but are made real by individual people we see. There are the children with no parents,  people with amputations and wounds coming for dressing changes, old people who’ve seen too much,  happy and beautiful children with the whitest teeth I’ve ever seen,  adults who are survivors of a tough environment that doesn’t allow for laziness or complaining.  People try to keep clean,  living under a tarp on the street but still bathing with a bucket of water that’s not so pure; possessions may be lost and destroyed but dignity thrives.

These are a religious people and God is not far away, a rock on which to depend during this time, not so much to question why but to thank for being alive and to help celebrate the memories of the lost.  These are a remarkable people.  Someone told me that you either loathe Haiti and can’t wait to leave its heat,  poverty and filth, or you come to love it and its people and the spirit that drives them.  I’m in the latter camp.  I’ll be back, to continue what’s been started and to help where I can.  I have much to teach and much more to learn and what better teachers?

Kaiser Permanente Hayward Medical Center


Finding Perspective in a Carrefour ‘Copy Shop’

I have been in Haiti for over a month now, working with Relief International.  It was only a few days ago, while waiting for photocopies to be made, that I had time to reflect on the gravity of the situation here.  While I waited at the “copy shop” I could only marvel at how quickly I adapted to the utter chaos and destruction around me.  On the way to the shop I did not find it strange to have our driver maneuver around rubble piles, or pass by one collapsed building after another, observing people bathe in the street water or shovel through the rubble for goods and loved ones.  I did not find it strange to skirt our way around a crushed vehicle parked in front of the crumbled shop, then watch the copy shop man power up a generator to run his single copy machine.

This realization also allowed me to reflect on what Relief International has been able to create amidst such chaos.  The Relief International fixed clinic in Carrefour has been running smoothly and orderly since Jan. 20.  Within the grounds of our clinic, one would hardly believe the chaos just beyond the property wall.  Our patients are getting healthier by the day, and it’s now unusual to see a true emergency waiting at our gate at dawn.  The same phenomenon occurs with our mobile clinics.  We often are greeted by a few very sick patients when we first arrive at a new mobile clinic site.  By the second visit at each site, chronic medical problems are the bulk of our patients’ medical issues.  So, despite the chaos outside our walls, Relief International is doing its part to ensure that the population it serves is getting good and appropriate medical care.  The impact within the communities we serve is undoubtedly obvious.

Relief International’s long-term goals in Haiti initially seemed overwhelmingly grand.  However, we are getting closer to the goal of setting up five fixed clinics each day.  Dr. Garzon returned to the U.S. and left big shoes for me to fill.  However, he worked hard with Relief International staff to lay out the groundwork for Relief International’s long-term mission.  Our clinic has seen more than 4,000 patients to date, and delivered one baby.  Several national support staff have been hired, and Haitian medical providers will be hired this week.  A large team of expatriate physicians, nurses, and paramedics joined our team to increase our mobile clinic capability, and to get our clinic programs and systems developed and running.  Relief International is continuing to work with the Haitian Ministry of Health to open the four other fixed clinics.

Our team’s energy remains amazingly positive and is the reason we work so efficiently and well together. It is because of this Relief International team that we have been able to find any kind of order within such chaos.  And, it was only after I stopped for a  few minutes in the copy shop that I realized how successful our work here has been.

Vivian Reyes

Kaiser Permanente San Francisco Medical Center

Sent from my iPhone

A Psychiatrist Reflects on His Time in Haiti

In our lives, few opportunities cross our paths that have the potential to change our perspective, direction and viewpoint — three hard-wired and difficult-to-change aspects of our personality and world view. In fact, these opportunities are so few and far between that we often spend much time, effort and energy attempting to find the events that will help us to see ourselves and our community in a different light.

Such an opportunity came to me two weeks ago when I received a call to come to Haiti. I knew then that the experience would change me as a person, but the jury is still out on exactly how much. But then, this is my personal journey.  And a deeply personal one at that.  It will be difficult for me to explain or describe what it is like here, but I hope that as you read this passage, you will begin to understand a bit about why this experience is so important. I also hope it gives you a window into the Haitian people, their suffering and their tremendous resiliency.

Relief International, an international humanitarian agency, has worked with The Permanente Medical Group to bring physicians to this devastated and impoverished landscape.  The people you expect to be here are here:  emergency room physicians and nurses, internists, surgeons.  But I am none of those.  I am a psychiatrist and have always wondered what my possible role could be in a land that is trying to exist day by day.  Would they have the time and interest in thinking of their mental health? I wasn’t sure that this would be a priority when one is looking for food and shelter, and neither do many relief agencies. Was I ever wrong.

I left for Haiti one week ago, amid a flurry of emotion. I was scared and anxious but elated, energized to be of service. I arrived in Santo Domingo in the Dominican Republic and the next day, took a convoy transport to Haiti. My first view of this land was at the barren and desolate border, an area of rock quarries and dirt. As we drove through the countryside, the devastation became apparent, and as we pulled into the U.S. Embassy in Port Au Prince, the full weight of the devastation was obvious. Individuals living in tent cities, or less, with little cover over their heads, through rainy nights.  Food was sparse, and children were begging for food. Immediately,  I was overwhelmed. I had never seen devastation on this scale, even when I visited Nigeria in the mid-1990s. This was human suffering at its worst.

Then I arrived at my lodging.  No running water, sparse electricity, and difficult living conditions. But at the heart of this house there was a dedicated team of workers from Relief International, a seasoned bunch who had worked extensively in parts of the world that most of us would never dare to tread.  In them,  I saw something that I had not seen in a long time:  a drive to sacrifice themselves and their comfort for the good of a people they had never met.  I was also surrounded by doctors and nurses who, like me, had sacrificed their time to come here. Immediately, the fear that I felt just days before melted away.

Later that night, I met the French psychologist from San Francisco with whom I would be working. Later, another TPMG doctor would join me,  and the team of us would work in Port Au Prince in a very special mission.

Through the vision of Relief International and their prioritization of the mental health care of the Haitian people, and of course, the support of my many colleagues, I participated in a very important program of psychosocial support.  Frequently, mental health is relegated to  second place status in disasters because there are perceived to be more pressing needs.  But Relief International saw a need and asked me to help fill it.  I was brought to Haiti to develop a program for staff training at a local hospital.

Nos Petits Freres et Souers, otherwise known as St Damien’s Hospital, is a local facility that is dedicated to those who suffer from “social leprosy.”  Their patron saint, Father Damien, was a man who worked in Moloka’i, Hawaii, with the lepers who had been exiled there.  And the mission of the hospital where I would be working was to provide sustenance for those children who were social lepers because their families had abandoned them for whatever reason. A staff of 200 attended to these children, and their bright smiles and shining faces greeted me as I walked through the gates.

But the smiles belied their suffering, and as part of my work, I would be providing debriefing to these staff, followed by training them in brief interventions with traumatized patients.  I was not prepared for what I would hear.

From a young interpreter who had lost his parents and a sibling and was living on the street, to the incredible story of a nurse who had lost 10 family members in the earthquake, I began to understand the extent of what these people had lost. In spite of the fact that they all were living in tents on the grounds, tent cities in the outlying areas, or walking the streets, they were coming to work.  They would walk up to three hours to get there, and in many cases, they were volunteers.  Freshly pressed, clean and better dressed than many of my American colleagues, they would come to work,  ready to serve their fellow patients.

Over and over again, I heard their coping strategies: to give thanks for what they didn’t lose, to provide for those who had lost more,  and to derive strength from their colleagues to move forward and god, was I amazed. A people that had lost so much could give thanks. Of course, they could shed their tears, talk about their loss and process what it meant for them. But they didn’t complain.  Repeatedly  I heard,  “I have so much compared to the woman next to me.  I have my work.  I have my family.  I must work as hard as I can to rebuild this country that I love.”

Mason Turner, MD

San Francisco Medical Center