Cover Story - April 2010
Tex Med . 2010;106(4):40-49.
By Ken Ortolon
Austin orthopedic surgeon Scott Smith, MD, watched the news coverage of the Jan. 12 earthquake that virtually destroyed the Haitian capital of Port-au-Prince and decided he had to do something to help the estimated 3 million people needing emergency aid after the quake.
"I have a pretty extensive background in trauma surgery. I saw all the people who were hurt, and that's what I do in my practice. I figured I'm a guy who needs to go down there."
Dr. Smith is emblematic of the outpouring of concern Texas physicians showed for the people of Haiti and their willingness to put their lives and practices on hold to help the injured there.
In the days and weeks following the earthquake, dozens of Texas physicians, along with medical students, nurses, physician assistants, and other health professionals, found their way to Haiti. Many went as part of organized missions, and most paid their own way. Some stayed only three or four days, others as long as two weeks.
They felt compelled to go.
"There were a lot of reasons to not go, but it felt like I absolutely had to do it. That isn't something I'd actually felt before," said Joanna Gibbons, a second-year medical student at the Texas College of Osteopathic Medicine (TCOM). "The issue became that I couldn't not go."
Even so, she knew it might be dangerous to venture into a country on the verge of collapse. Before leaving, she wrote good-bye notes to her parents in case she didn't return alive.
Ms. Gibbons was in one of the first Texas groups to arrive in Haiti. Her group, which entered the country just four days after the quake, included fellow TCOM medical students Bill Betz and Stephen Miller, as well as former TCOM Interim Dean Bruce Dubin, DO.
The group was not part of a formal mission but was able to connect with leaders of the Church of Christ of Latter Day Saints (LDS) in Haiti who took them across the border from the Dominican Republic to sites where they could set up what Ms. Gibbons described as "mini-clinics."
She and the rest of the group paid their own airfare to Santo Domingo, then drove six hours to the Haiti border. She and Dr. Dubin both say the scene there was chaotic.
Ms. Gibbons says there was a vast sea of Red Cross tents where throngs of people coming out of Haiti were getting medical care and supplies. One pickup truck with two injured people in its bed crossed the border and was swarmed by news reporters and TV photographers.
But there were more people trying to enter Haiti than leave, she says. It took two hours to get across the border.
"My first impression was one of chaos and lack of organization," said Dr. Dubin, now dean and chief academic officer at Rocky Vista University College of Osteopathic Medicine in Colorado. "It was obvious to me that no incident command structure or organization had been set up. The border was extremely chaotic, the utilization of resources and supplies was chaotic, and the devastation - especially in downtown Port-au-Prince - was just amazing."
Once they arrived in Port-au-Prince, they found the destruction overwhelming. Ms. Gibbons says many buildings were flattened, while most of those still standing had cracks in their walls.
Unlike the turmoil on the border, Ms. Gibbons says the LDS group was well organized. They had medical and other supplies shipped to a small town about 30 miles from Port-au-Prince. From there, supplies were distributed to various churches in the area.
"They plugged us into their system, and we became another one of their supplies," she said.
For four days, the students and Dr. Dubin operated a small clinic at four churches and cared for parishioners of the churches.
Dr. Dubin says they saw a wide range of injuries and ailments, including lacerations, broken bones, head injuries, infectious diarrhea, and compartment syndromes, where blood flow had been cut off to arms or legs for extended periods.
"The bad thing was the infections that were starting to set in to people who had been injured, and they were running the risk of losing their limbs, especially the kids," Dr. Dubin said.
And, they didn't always have the necessary supplies. One of the medical students resorted to rolling up newspapers to make a splint for a fractured tibia, Dr. Dubin says. "We did a lot of improvising. You improvise with what you've got."
Help for the Refugees
The same day the medial students reached Haiti, a group from Fort Worth arrived at a hospital in Pierre Payen, a coastal town some 30 miles north of Port-au-Prince on one of the evacuation routes out of the city. The group included trauma surgeon Robert Sloane, MD, and his wife, Robin, executive director of the Tarrant County Medical Society; Fort Worth pediatrician Ric Bonnell, MD; Belton emergency physician Jerad Mabery, MD; and a paramedic.
They went in under the auspices of Project Help Haiti, which had an established hospital in Pierre Payen. They brought many of their own supplies with them, including antibiotics, bandages, intravenous solutions, anesthetic agents, food, and water.
The hospital had a small guesthouse, so the relief team had relatively comfortable accommodations, Dr. Sloane says. "We had beds to sleep in as opposed to sleeping on the ground. We had purified water, we had someone to cook for us, and we had enough anesthetic to really do things just like we would here at home."
Dr. Sloane says the devastation in Port-au-Prince and the coastal city of Leogane was so extensive that "everybody was touched. In Leogane, they're still sleeping in the fields. The whole town was destroyed. The hospital is possibly salvageable, but no one was going in."
The team saw mostly refugee traffic, "which determined what kind of injuries we saw because they had to get out that far," Dr. Sloane said. "Some people actually had traversed Port-au-Prince from the other side, had come from the western part of Haiti through Port-au-Prince out to where we were."
The group treated mostly orthopedic injuries and soft-tissue wounds, he says, including "fractures of everything imaginable, some of them compound," as well as neurologic injuries.
"And we had some crush injuries with acute renal failure," he said. Sadly, they did not have the necessary equipment to deal with acute renal failure.
"We told one young guy there was nothing we could do for his renal failure," Dr. Sloane said. "Before he decided he'd just go home, he wanted everybody to pray for him."
Dr. Sloane says they had no orthopedic surgeons in their team, so they acted largely as a triage team, debreeding and dressing wounds, setting closed fractures, casting broken arms and legs, and putting people in traction, if necessary.
"The next team that rotated in was all orthopedists, so they brought orthopedic hardware to start fixing the more complicated fractures. We left them a bunch of femur fractures and complicated open ankle and elbow fractures."
"It Was Madness"
Another group that arrived in Haiti a week after the earthquake included two assistant professors at the Texas Tech University Paul L. Foster School of Medicine in El Paso. Family physicians Marco Diaz, MD, and Leonardo Loaiza, MD, paid their own airfare to get to Santo Domingo with hopes of finding transportation from there to the airport in Port-au-Prince. Other medical groups flying into Port-au-Prince turned them down due to lack of space; however, a man who owned his own jet plane offered them a lift.
They arrived at Port-au-Prince at 4:30 am on Jan. 19 to find the airport almost destroyed, journalists and rescue workers sleeping in what was left of the terminal, and thousands of Haitians outside looking for a way to leave Haiti.
Dr. Diaz says they tried to walk from the airport into Port-au-Prince but were mobbed by people asking for food or water. Before leaving El Paso, they contacted Artists for Peace and Justice, which connected them with St. Damien Pediatric Hospital in the Haitian capital. They eventually got hospital workers to pick them up at the airport and drive them through the city. Thirty-six hours after leaving El Paso, they finally reached their destination and were put to work immediately, not even given time to unpack the medical supplies they had taken in their luggage.
"We met a physician who had been there since the day the earthquake hit," Dr. Diaz said. "He pulled us aside and said, 'Put your bags down, and let's get to work.' It was madness. We had people who had been lying there for six or seven days without any kind of pain medication, without antibiotics, without IV fluids, without anything."
Dr. Diaz was assigned to begin setting and casting broken arms and legs. He says there were numerous exposed and "grossly disfiguring" fractures.
"I was immediately overwhelmed," he said. "I had to pause for a moment and find a little room somewhere where I could gather my thoughts and just take a deep breath."
"We Assumed That They Had Absolutely Nothing"
While some physicians made the trip to Haiti on the spur of the moment, others joined more organized relief efforts.
Some 50 to 60 physicians from the Lower Rio Grande Valley were part of an effort by Hope International Medical Missions that sent five separate teams to Haiti for one-week stints to provide care.
Harlingen obstetrician-gynecologist Miguel Cintron, MD, a trustee of the mission organization, says groups of about 20 people, including physicians, nurses, and other support personnel, and clergy, went to a hospital in Fort Liberte, a city in the northeastern part of Haiti. Each team treated patients for one week, with the next team arriving the day before the previous team left so the physicians could sign off care of patients to the new team.
The initial group chartered flights from Texas to Fort Lauderdale, then took commercial flights to Haiti. All of the physicians paid for their own airfare and accommodations in Haiti. Hope International did use some of its donations to pay for airfare and hotel accommodations for others on the team who could not afford to pay out of their own pocket, Dr. Cintron says.
The first team arrived in early February, carrying roughly 1,000 pounds of medical equipment and supplies. Another 2,500 pound of supplies arrived a few days later.
"We assumed that they had absolutely nothing, no monitors, no EKG machines, other minor medical supplies such as wound dressings, materials to set casts, or surgical instruments," Dr. Cintron said.
While volunteer physicians who went in immediately after the earthquake were dealing with a lot of trauma, Dr. Cintron says much of the care by his group involved a large number of infections and chronic diseases, such as high blood pressure and diabetes.
There was an added bonus to treating the earthquake victims besides the sense of satisfaction of helping people in desperate need, Dr. Cintron says. That was being able to take a break from the hassles of American medicine.
"We didn't worry about how much they're going to pay us, or who's going to pay us, or whatever. We knew we weren't going to get paid. We were just there to help people."
While physicians who traveled to Haiti with the Hope International group treated mostly infections and chronic illnesses, a group of Austin orthopedic surgeons that included Dr. Smith dealt with the aftermath of what one of the physicians described as "battlefield-type" amputations.
"We'd heard all the ghastly talk about amputations being done on the side of the road with saws pulled out of somebody's car, no anesthesia," said orthopedic surgeon Michael Loeb, MD, of Austin-based Texas Orthopedics, Sports & Rehabilitation Associates. "We knew there was going to be some of that. I don't think there was really an option. Some of those people were literally trapped under the rubble and could not be excavated in time, so it was truly a life-or-limb situation."
Dr. Loeb and Dr. Smith were part of a group of 18 people sponsored by Texas Orthopedics and Hill Country Bible Church that arrived in Haiti on Jan. 23 and set up surgical operations at Mission of Hope Haiti just outside Port-au-Prince. Now named Austin Medical Relief for Haiti, the group comprised 13 physicians, including orthopedic surgeons, anesthesiologists, and emergency physicians. It also included nurses, technicians, and nonmedical support personnel.
Dr. Smith says the team knew they would see devastating injuries, but the number of them was overwhelming.
"Here, you see one traumatic amputation a month or maybe a quarter," Dr. Smith said. "There, we saw six or eight the first day we were there. The volume of people who were injured was just unbelievable."
Austin emergency physician Adrian Martinez, MD, also was part of the Austin Medical Relief team. He says providing optimal care was challenging because they did not have all the necessary equipment, such as an x-ray machine.
Singing Through Surgery
Many of the physicians who went to Haiti say their efforts were highly gratifying. The Haitians are resilient people with a strong religious faith that helped them weather the ordeal, they say.
One incident in particular amazed Dr. Loeb and his colleagues. Without proper anesthesia-monitoring equipment, they had to perform amputations with only spinal anesthesia. They were cleaning up emergency leg amputations on two women at the same time in the same operating room when one of the women began to sing Christian hymns, Dr. Loeb says. Soon after, the second woman joined in.
"We were all very moved by that experience," Dr. Loeb said. "It's hard not to think there's some higher power out there that was allowing these women to manage what is a devastating injury. To find that kind of faith in that situation, that's not a common finding."
"I was tearing up. I had to stop operating," said Dr. Smith, who also was involved in those procedures. "I will never forget the sounds of their voices."
Dr. Martinez says he treated a pregnant woman who was separated from her 5-year-old daughter. The daughter went to a different hospital. While the woman lost a leg, she and her baby were saved.
Unfortunately, the daughter died, and the family chose not to tell the woman for several days. Dr. Martinez says it was very emotional watching her grief when she finally learned her daughter had died. "It was pretty rough for the whole team because we got to know her pretty well."
In late February, more than a month after the earthquake, other groups of Texas physicians were still planning their Haitian relief efforts.
Wichita Falls gastroenterologist Louis Wilson, MD, says the North Texas Medical Mission planned to send eight physicians, three nurse practitioners, one physician assistant, three nurses, a pharmacy technician, clergy, security personnel, and 60 crates of medication and other supplies.
The group also worked through the Mission of Hope and had an advance team on the ground in Haiti scouting potential locations to establish clinics.
Dr. Wilson says they expect to provide treatment for infections, diarrhea, asthma, allergies, skin care, wound care, postsurgical skin care, and other conditions.
"We expect 40 percent of patients to be children, which is more than we've experienced with other disasters," he said.
The Wichita County Medical Society Alliance also was working in late February to mount relief efforts for Haiti. Bob Horth, one of three mission directors for the Wichita CMS Alliance, says the group has raised $60,000 for Haitian relief. The alliance had yet to determine how to use that money, but Mr. Horth says it is highly probable it will send a medical mission to the country.
The Need Remains
Dr. Sloane, the Forth Worth surgeon, says physicians who responded to the medical needs of Haitian quake victims likely saved hundreds, if not thousands, of lives of people who might have died from infections or other causes. But the short-term need will eventually morph into longer-term needs as these people attempt to rebuild their lives. Thousands are still homeless, and the elderly, young children, amputees, and paraplegics can't compete with the able bodied for food, water, and tents handed out by relief workers.
He adds that there will be an ongoing need for prosthetic limbs, follow-up care for paraplegics, and other services.
"The volunteerism and excitement about the immediate crisis is one thing, but it's the sustainability of resources and health care providers that's the real issue," added Dr. Dubin. "It's that ongoing provision of health care that will be extremely important."
While many of the physicians, medical students, and others who volunteered in Haiti had previous experience with disaster relief and medical missions, some had never been involved in such work. Some say the experience has changed their lives.
Ms. Gibbons, the TCOM student, says her trip to Haiti helped her focus on what she wants to do in her career.
"I had been really confused about what I want to do with my career," she said. "But now I'm pretty convinced that whatever field I end up choosing I want to be deeply involved in international aid and disaster relief."
And Dr. Dubin says Ms. Gibbons and her fellow students did extremely well under very frustrating conditions.
"There are some kids walking around Haiti today who did not have a hand or a leg amputated because of the wound care that the medical students provided," he said. "That's a big deal.
"The students who went did this at their own expense, made it happen on their own," he added. "These are the kind of docs Texas wants."
Ken Ortolon can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by e-mail at Ken Ortolon .
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