Tag Archives: Garzon

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

Dr. Garzon Reflects on His Second Tenure in Haiti

As I prepare to leave here in two  days – one month after the earthquake – I’m struck with how much unmet need still exists, and also how much the character of this response has changed.

Our first days on the ground were characterized by a largely lawless, extremely chaotic, life-saving emergency response to the traumatic injuries caused by an earthquake. This was all complicated by terrible communications, no accurate information, and essentially no coordination as both the Haitian government and UN lost many staff and buildings to the earthquake.

At this stage, while the needs for food, water, sanitation, shelter, health care, and other things is still tremendous, there is most definitely a different urgency, coordination, and capacity to respond. While our program and the response as a whole is a continuation of what was started on Jan. 12, to look at where we were on day one of the response and where we are now is almost like looking at a caterpillar and a butterfly.  Along the way, there has been some transformation.

As I prepare to leave, we are in the process of standing up five clinic sites, have more than doubled our volunteer staff, and are preparing to develop comprehensive primary care programs in coordination with Haitian health care staff and the Ministry of Health.  My last week, and the work to come, will focus on developing programs at these clinics that provide comprehensive reproductive health programs, mass immunization programs, malnutrition screening and treatment programs, and full-service primary care for chronic conditions.

I will have the fortune to continue working on this relief effort from home, and hopefully will continue to find volunteers who are interested in joining the efforts here with Relief International over the next year or more. As long as there is unmet need, our work is not over.

When I have improved internet access I will have the chance to post more pictures!  Thank you all for your support!

Hernando Garzon, MD

Dr. Garzon Returns to Haiti

It’s been many days since I’ve sent any updates, and I could probably write a book about the past three days alone. I’ve been back to Haiti for three days but is seems like a lifetime!

Suzy Fitzgerald led the Relief International emergency response medical team through the first week of work, seeing more than 2,400 patients. We have had nine physicians, three nurses and a paramedic on the medical team (nine of these from Kaiser Permanente). In the humanitarian relief world, organizations usually either do emergency relief or development.  Relief International is one of the few organizations I know that does both well. We have been running a single fixed clinic and occasional mobile clinics in the Carrefour area, just east of Port au Prince, near the epicenter or the earthquake. While our clinical staff has been very busy with patient care, Relief International’s staff has been busy applying for additional funding to continue relief operations and establish development programs.

Our presence here doing disaster relief has contributed significantly to the success of qualifying for the two grants for which RI has applied. Four weeks after the earthquake, much remains to be done. There are many people who still need definitive care for infections, poorly healed fractures, amputations, and other trauma from the earthquake. In addition, the mental health, physical therapy, and occupational therapy needs are huge. At the same time, there is a rebuilding process that has to begin for the entire society.

Relief International has received two grants to continue the health sector rebuilding process. The bigger one is for six months and includes funding to establish five primary care clinics staffed by both local health care providers and international volunteer staff. We will continue running the current clinic and have tentatively identified sites for the five others. In addition, we have been busy looking into sources to hire local health care staff and have made an affiliation with one of the five collapsed medical schools in Port au Prince. This will allow additional training of local health care providers and contribute to the “capacity building” work done by RI. We are also looking to bring in another large cadre of volunteers from the U.S. before the end of February to support these clinics.

The second grant is to create a service that hasn’t previously existed here, which will fill a huge gap in the current health situation. There are many patients who are in health care facilities that need transport to a different facility, but there is no existing ambulance or patient transport service. Relief International has been given a grant that will support a five-ambulance “Critical Care Transport” team to fill that gap. Here again there is a need for more physicians, nurses or medics to help run this system for the next two months. This as well is under construction, and should be up and running within a week. We expect to bring in another 15 clinical volunteers before the end of February.

My apologies if this brief summary of a hugely complex process loses a bit of the intensity of what is going on here. In the midst of this continued chaos, the medical team is still doing incredible work. Our initial team is largely home and we have a second wave of incredibly motivated volunteers. It is an honor to be here to help. In the face of tremendous suffering there is still amazing opportunity and hope. We just have to get comfortable with the incredible uncertainty that also exists. Perhaps the attached pictures can say more about what the work is about than these words…. In the morning, our clinic day starts by doing a visual triage of the usually long line that begins to build around 4 a.m. We triage the sickest to come in first and then take the others as first come, first serve. One picture is of this triage of the morning line which on this day was 180 people long. The second picture is of one of our nurses with one of those sick babies that was seen first.

-Hernando Garzon, MD




Dr. Fitzgerald Leaves ‘With a Hopeful Heart’

Feb. 1, 11 a.m. I’m on the tarmac at the Port au Prince Airport waiting for the military flight that will begin my trip home. I wish more than anything to stay here in Haiti and continue this work, but professional obligations require my presence elsewhere. I hope to return very soon.

In the meantime, Dr. Vivian Reyes will be taking over as the Med Team Leader, and Dr. Hernando Garzon will be returning to Port au Prince in a few days.

It seems a lifetime ago I was frantically packing and repacking my bags and making all those trips to REI.  I remember the military helicopter in from Santo Domingo, the land below turning from the lush green of the Dominican Republic to the stark destruction of the Haitian landscape.  I remember landing at the U.S. Embassy and meeting the rest of the team and then taking that first SUV ride through the rubble-filled Port au Prince streets.  I remember the first patient femur fracture we treated, the first wound infection that improved, and the first time I said a shy “Bonjour.”

I remember the Haitian people beginning to live again — hearing it in the rhythmic strike of hammers and seeing it in the effortless posture of the graceful Haitian women returning from market with large baskets of food balanced perfectly on their heads.

I remember everything, yet at the same time nothing — the past two weeks has been a blur of sweat, dust, exhilaration, and fatigue.

I am proud to have worked with such an incredibly dedicated group of providers and workers.  Tremendously grateful to Kaiser Permanente and Relief International for getting us on the ground so quickly, and supporting us so well. Thankful to Medshare for those initial supplies, and extremely gratified to feel we have already helped, in whatever small way, 2,000+ patients affected by this event.

The Relief International program expands daily. In addition to the operation and expansion of the fixed and mobile clinics, several partnerships with the local pre-existing Haitian health care system are in the works. Capacity building has begun.

I also know the people of Haiti continue to need as much help as they can get. They need it today. They’ll need it tomorrow, the next day, and next month. They’ll need it for a long time and your support is crucial to the Relief International effort. Please donate what you can — your time as a volunteer, your money to the Relief International team, or your understanding when your KP colleagues drop off the work roster to head to Haiti for a few weeks.

There will be ongoing opportunities for KP physicians to volunteer in Port au Prince as the site becomes fully integrated into the KP Global Health Program.

What we have begun in Carrefour, Port au Prince is only a drop in the bucket — but at least there IS a bucket.  We can fill it together, one drop at a time.

I leave Haiti with a hopeful heart.

Suzy Fitzgerald, MD
Relief International
Kaiser Permanente – Diablo Service Area
Sent from my Verizon Wireless BlackBerry

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


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

Deploying Mobile Clinics

Greetings from Carrefour, Port au Prince, Haiti.

With the fixed clinic in Carrefour up and running, we have now been able to turn our attention to the mobile clinics.  We are targeting several areas identified by the Ministry of Health as especially in need of this service.  Sunday morning we loaded up our two-vehicle convoy complete with three MDs, one RN, and multiple expat and national staff, and left our fixed clinic at 8:30 am.  We set up shop at Tabanarre de la Grasse, an Internally Displaced Persons camp on the site of what used to be a school and orphanage.  After a whirlwind of activity, the team had the tents and the clinic up and running by 10:30 am.  By noon we had done our first two acute care transfers.  By 3 p.m., we had seen 114 patients. We estimate 30 percent were in urgent need of our services and would have become sicker without this medical intervention.  We continue to see previously untreated earthquake injuries and many wounds that have now become infected.

We also continue to operate our fixed clinic and gave medical treatment to 148 patients.  The plan for Monday is more of the same, including setting up a new mobile clinic at a large IDP camp near what used to be the Prime Minister’s office.  We will run this clinic directly out of the backs of our trucks.

As you might imagine, our team is tired but extremely happy to have reached this many Haitians.  We have everything we need thanks to the incredible hospitality of Dr. Catherine Wolfe and Cherlie Severe, RN.  They normally live and operate Friends For Health in Haiti near Jeremie, Haiti, and have opened Cherlie’s home here in Carrefour to us for both our living and our fixed clinic space.  The aftershocks continue and most of us sleep outside, but frankly, it’s quite nice to sleep under the Haitian sky.

We continue to believe there is a great deal of urgent unmet need out there, and will be working very hard to find and treat those patients.

We would like to thank everyone for the incredible support and heartfelt wishes.  All of it means a great deal to our team.  Between the support of those back home and the gentle and grateful smiles of the Haitians, our spirits and energy levels remain high.  Thank you all for helping us to do this work.

And a special thank you to the team here on the ground, who do anything and everything when asked and even when not asked, and do it with unfailing energy and good humor: Josh Weil, MD (Kaiser Permanente Santa Rosa), Vivian Reyes, MD (Kaiser Permanente San Francisco), Stephen Bretz, MD (John Muir Medical Center, Walnut Creek, Calif.), Catherine Wolf, MD (Friends For Health In Haiti), Linda Martin, RN (Kaiser Permanente Morse Sacramento), Kelly Belli (Kaiser Permanente Morse Sacramento), Cherlie Severe, RN (Friends For Health In Haiti), Barbie Law (Captain-Paramedic, Sacramento Metro Fire), Don Engle, DDS (Lafayette, Calif.), Serena Clayton (California School Health Centers Association), Mike Speaks (Denali Park, Alaska), Andrew Johnston (Project Coordinator, Relief International), and Tiare Cross (Team Leader, Relief International).  Hernando Garzon MD, who led the initial effort and established the team in Haiti, continues to be very much involved from the United States.

More later, we are heading out for clinics now.

Thanks to all!

Suzy Fitzgerald, MD
Medical Team Leader
Relief International
Kaiser Permanente Diablo Service Area

Update from Suzy Fitzgerald MD, January 26, 2010

Need to Expand Access

Our clinic continues to see patients, while we assess the situation and coordinate with the WHO efforts around health issues for the entire event. It is likely we will also look at either opening a second clinic and/or become involved with mobile clinics which will get us to more difficult to access pockets of population which have not yet had any medical care.

I will be traveling home earlier than expected for family reasons, but am hoping to return shortly to continue this vital work! This is only the beginning of a long process of recovery for the people of Haiti.

In my absence the medical team will be lead by Suzy Fitzgerald, MD from Kaiser Permanente Walnut Creek’s emergency department.  Hopefully she will continue blogging the team’s experiences.

Update from Hernando Garzon, MD, January 23, 2010.