Relief Work in Haiti. Viewing Time. Faculty Disclosure. Target Audience. Faculty Disclosure 7/10/2010

Transcription

1 Viewing Time This presentation will take one hour to complete. Target Audience This program is designed for primary care physicians. Other health care professionals working with patients and their families may also find this program of interest. Faculty Disclosure It is the policy of Children s Hospitals and Clinics of Minnesota to ensure balance, independence, objectivity, and scientific rigor in all its educational programs. Our faculty have been asked to disclose to our program audience any real or apparent conflicts of interest related to the content of their presentations. They have also been requested to let you know when any products mentioned in their presentations are not labeled for the use under discussion or are still under investigation. Faculty Disclosure Betty Wu, M.D. and Jennifer Halverson, M.D. have disclosed no actual or apparent conflict of interest in relation to this educational activity. During this educational activity Dr. Wu and Dr. Halverson will not be discussing the use of any commercial or investigational product not approved for any purpose by the FDA. Relief Work in Haiti Betty Wu, M.D. Pediatric Emergency Medicine Children s Hospitals and Clinics of MN Jennifer Halverson, M.D. Fellow: Pediatric Emergency Medicine Children s Hospitals and Clinics of MN 1

2 Relief Work in Haiti Two accounts by physicians who served in the emergency medicine relief efforts in Haiti in the early weeks after the 2010 earthquake. Program Objectives Upon completion of this program, participants should be able to: Describe the most common earthquakerelated injuries encountered in the January 2010 Haiti earthquake. Describe the process of triaging and treating severe traumatic injuries (especially extremity injuries) in a relatively resource-poor setting. Describe the variety of post-operative complications without adequate follow up care. Disclaimer Children s Hospitals and Clinics of Minnesota accepts no responsibility for the materials presented through these Grand Rounds seminars. Each professional presenter assumes all responsibility for maintaining confidentiality or obtaining authorization, in accordance with all applicable laws. Accreditation Children s Hospitals and Clinics of Minnesota is accredited by the Minnesota Medical Association to provide continuing medical education for physicians. Children s Hospitals and Clinics of Minnesota designates this educational activity for a maximum of 1 AMA Category 1 Credit TM toward the AMA Physician s Recognition Award. Each physician should only claim credits for the time that he or she actually spent in the activity. Receiving CME Credit Haiti Earthquake Relief: Twenty-one days on the Comfort To receive CME credit, you must view the entire program and complete the evaluation form at the end. Betty Wu, MD 24 th March

3 Outline On Tuesday, January 12, 2010 a 7.0 magnitude earthquake struck Haiti Brief overview of experience Preliminary data Illustrative cases Acknowledgements : Astrid Riecken & Paul Firth Hughes Larosa 28/1/2010 USNS Comfort Epicenter was located 15 miles SW of Port-Au-Prince Population of Port-au-Prince - approx 2,000,000 Population of Haiti - Approx. 9,000,000 Estimated dead >200,000 80% of population living < poverty line 14 January 23, 2010 Jan 26th Project Hope Volunteers Jan 26th Congratulations, you ve been selected to participate in the first 3-week rotation as a Pediatrician aboard the USNS COMFORT providing Humanitarian Assistance and Disaster Relief to the Haitian people as part of Operation UNIFIED RESPONSE. Your scheduled deployment date is Tue, January 26, Jacksonville, FL. Jan 27th Port-au-Prince Airport Jan 27 th p.m. 3

4 Helo to ship Jan 27th USNS Comfort USNS Comfort and the USNS Mercy Helicopter or Boat transport Triaged from LZ s Converted Oil tankers in bed capacity 4 ICU s = 80 beds plus 20 recovery beds 12 Operating rooms Digital xrays and CT/US As long as 3 football fields 21 To OR? Cas-rec 24 4

5 26 Wards 5

6 ICU/PICU/ NICU Sedations 32 USNS Comfort Age Distribution 6

7 PERCENT OF EARTHQUAKE & NON EARTHQUAKE RELATED CASES 0000 EST 10 Feb 2010 Non-Earthquake related cases N=664 Earthquake Related N=99 Non-Earthquake Related N=763 Total number of patients seen since Jan 19th 13% of total patients seen were non-earthquake related 37 Tetanus Sydenham s chorea Hydrocephalus MVA s and other accidents HIV TB Kwashiorkor Tumors 38 Discharge onto land Discharges Receiving facilities Discharge: St. Damiens Hospital 7

8 Discharge: Airlift USA 44 Jennifer Halverson, M.D. Pediatric Emergency Medicine Fellow Children s Hospitals and Clinics of Minnesota University of Minnesota Department of Pediatrics 45 Describe the most common earthquake-related injuries encountered in the January 2010 Haiti earthquake. Describe the process of triaging and treating severe traumatic injuries (especially extremity injuries) in a relatively resource-poor setting. Describe the variety of post-operative complications encountered when patients with traumatic injuries are discharged without adequate follow up care. 8

9 Magnitude 7.0 Struck at 4:53 PM local time on 1-12 Epicenter located 10 miles WSW of Port au Prince, at a depth of 8 miles Two major aftershock (magnitude 6.0) One occurred 7 minutes after initial quake One occurred on 1-20 centered in Port au Prince Over 60 significant aftershocks (magnitude 4.5 or greater) First major earthquake in over 200 years Haiti estimated population: 10 million Estimated earthquake deaths: 222,570 killed (1 in 50 people) Estimated earthquake injuries: 300,000 Estimated displaced persons: 1.3 million Majority of infrastructure collapsed (hospitals, schools, government buildings, prisons) Epicenter located so close to a major city Shallow origin of quake Poverty Port au Prince is one of the worst constructed cities in the world Cinder block houses unable to withstand sideways vibrations caused by Strike-Slip type of fault line 9

10 10

11 11

12 Extensive damage over a wide area Many people inside at time of quake (though many outside were injured and killed as well) Cinder block construction of houses and other buildings Many businesses/dwellings surrounded by walls (many of which collapsed) Very substandard medical infrastructure prior to quake Many hospitals and clinics destroyed in the quake Many medical personnel killed in quake Many injured visited multiple medical facilities but were turned away Gen moun ki pi grav pase mwen First aid ( premye swen ) often the only care rendered for a week or more Established in Haiti in 1990 by an American couple from Boston Facilitates several programs including: Two small orphanages for children awaiting adoption Women s prenatal program, midwife birthing program, and post-natal early childhood development & education program Microfinance and sewing program for women Literacy classes for women Own or rent 7 houses in one neighborhood in Tabarre (close to the Port au Prince airport) Sustained only damage to the walls and minor structural damage to the houses All were deemed safe for ongoing use Walls rebuilt within a week 12

13 Well-established in one large Port au Prince slum (Simon Pele, or Pele ) Within days of the quake, Heartline was asked to provide emergency medical care to injured residents of Simon Pele and the surrounding areas Heartline personnel visited several locations and determined the need for medical services was great Supplies and personnel already in Haiti procured and organized Chartered flights (IBC Airways out of Fort Lauderdale) arranged to bring in medical personnel and supplies 1-2 times a week I was asked to join the relief efforts as soon as possible First chartered flight on 1-17 brought in many medical personnel and over 2000 pounds of supplies, medications, and food Clinic/ER/OR opened 1-18 in a house formally used for the sewing program Initially staffed by 4 MDs (myself, EM, anesthesiologist, and FM), 3 midwives, 5 RNs, 1 paramedic, 1 EMT, and over 15 support personnel (translators, drivers, security, etc) Additional MDs (podiatry, EM, IM, and OB) and RNs arrived within several days Pharmacy run by an RN No lab or x-ray capability Americans, Canadians, and Haitians worked together Clinic/Hospital located about a 5 mile drive from Pele Large covered truck used to transport injured patients from Pele to Heartline 3-4 times a day initially Other pick-up locations added due to overwhelming need (Cité Soleil, Wharf Jeremie, Aviation tent city) 13

14 14

15 Patients brought by the truck triaged in clinic yard by RNs and EMTs Outer bandages taken off, wounds soaked IVs placed, pain medications administered, initial wound care done Walk-in patients also treated Patients with most severe injuries brought inside to the makeshift OR area as space was available 15

16 Patients requiring invasive procedures triaged inside to the OR area Wound debridement ( make it bleed ) Fracture reduction (closed and open) Splinting/traction Laceration revision Fasciotomy Amputation (mainly fingers and toes) All painful procedures done under sedation (typically Ketamine) No regard for NPO status Pulse oximetry used when available Open infected wounds/gangrene Crush injuries Fractures (all diagnosed based on PE) Closed fractures Open fractures Multiple fractures Deep lacerations (unrepaired or poorly repaired) Puncture wounds Very little significant chest/abdominal/head trauma (presumed that most had died by this point) VAST MAJORITY HAD RECEIVED NO CARE OTHER THAN FIRST AID & BASIC DRESSINGS 16

17 17

18 18

19 19

20 20

21 21

22 22

23 23

24 24

25 All procedures done clean/ semi-sterile Instruments boiled and sealed in sterile bags All wounds considered to be infected and contaminated All patients with significant wounds and/or open fractures given IV antibiotics Discharged home with PO antibiotics (if stable to go home) or IV antibiotics continued (if inpatient) Tetanus vaccine not available until week #2 Outpatients received daily dressing changes and ongoing debridement as needed Inpatient ward created on day #1 (initially in the ER/OR house, then moved to a second house on day #3) Charting system developed that is still being used today Haitian staff who previously worked in Heartline s orphanages as nannies now worked in the hospital 25

26 Communication (cell phone service very limited) Internet service decent International cell phones (Blackberry) for texting and e- mailing Haiti cell service slowly improved over time Diesel shortages (used to run generators, trucks) No city power until March Required going to the Dominican Republic to purchase Medication shortages (especially morphine and some antibiotics) Alternative antibiotic regimens used temporarily Traded meds with other organizations (Salvation Army, the Germans ) 26

27 Lack of adequate MD and RN coverage for the inpatient ward Additional MDs and RNs recruited Lack of Tetanus vaccine UN delivered Td during week #2 Large expanding crack in OR wall Engineers reinforced with floor-to-ceiling hardware Disaster tourists Inability to transfer patients to a higher level of care** Located in a soccer stadium in Port au Prince On the ground and operating within days of the quake Quickly overwhelmed by the huge need for surgical services We attempted to bring 5 critically injured patients to them after our 1 st day; only one patient accepted due to no space Provided essential stabilization surgical care to many in the first week after the quake Many patients discharged on POD #1 External fixators and other hardware in place Discharged home No follow up care due to need for quick turnover Patients instructed to follow up with local orthopedic surgeon 27

28 28

29 Previously in Haiti spring 2009 for medical mission Arrived in Haiti 1-19 Started accepting patients 1-20 Made contact & spoke with one of the ship s captains the morning of 1-20 Four vehicle convoy with 11 of our most critically injured Patients delivered to ground location then airlifted (by helicopter) to the ship Initially accepted all surgical patients we brought to them including our most complex cases (open fractures, femur fractures, spine injuries, pelvic fractures, severe crush injuries) ORs and inpatient wards filled up with patients needing multiple operations Various surgical specialties available at different times Difficult to transfer patients by the end of January 29

30 Medishare has been facilitating medical work in Haiti since1994 Opened a large tent hospital at the Port au Prince airport about a week after the quake, with a staff of over 100 Large tents house ORs, PACU, adult ward, pediatric ward, PICU, NICU, pharmacy, and supplies Accepted many patients from Heartline, including those with non-earthquake related conditions (acute abdomen, neck abscess, emergency C-section) Many surgical specialties present Unable to accept some complex injuries, at least initially (pelvic fractures, spine injuries, some femur fractures) 30

31 First 7-10 days intensely focused on triaging and treating severe injuries, and transferring patient to higher level of care as needed During the first week, 2 paramedics from NYC arrived via the D.R. Began doing triage and some wound care in the community Continued to transport patients to and from the clinic/hospital Staffing needs changed Physical therapy services started end of January Orthopedic and emergency medicine PAs recruited to lead the truck teams and provide orthopedic expertise Med/peds MDs staffed inpatient ward Nurses worked 12 hours day/night shifts Paramedics and EMTs staffed truck team Support personnel Inpatient ward continued to grow Most earthquake-injured patients required daily dressing changes (many required sedation) Growing population of patients with non-earthquake related conditions, both from walk-in patients and those found by the truck team in the community Connection with MERLIN (UK medical relief organization) in early February Dozens of patients received skin grafts Many received orthopedic intervention Heartline provided post-op care for our patients Began accepting post-op transfers from both MERLIN and the USNS Comfort in early February MERLIN visited 2x/week to facilitate surgical follow up Acquired growing population of patients who needed orthopedic surgical care not available on the Comfort or at Medishare or MERLIN (especially femur fractures) Made new connection with Double Harvest hospital first week of February Orthopedic surgical teams from Michigan Ability to convert femur ex-fix to ORIF, even up to 6 weeks post-injury Accepted the last patient off the Comfort on 2-27 Truck runs less frequent over time, eventually down to 3 days a week Commitment to seeing each patient (both inpatients and those we are following in the slums) through to the end Cast removal Ex-fix removal Coordination of care/transfers required large commitment of time & resources Inpatient ward still currently operational 2 patients to receive follow up plastic surgery this AM at Medishare (both were Comfort transfers) Nothing is easy to accomplish in Haiti Communication in-country is often difficult Transportation is difficult (and painful) and slow due to poor roads and traffic 2 hours to drive 2 miles one day, 20 minutes the next Surgical teams typically only in-country for 5-7 days, so surgical capabilities at various hospitals changed quickly Equipment not available to do certain operations Things break down frequently (trucks, generators, internet, etc) Post-op care is fraught with potential complications that can be difficult to address 31

32 Tachycardic, febrile, and in severe pain Presumed wound infection Treated with Zosyn Transferred back to Comfort 2-20 to 2-24 U/S showed small seroma/hematoma, treated with compression Transfused prbcs Improved dramatically on antibiotics Very poor knee mobility despite intensive PT Attempted knee manipulation under deep sedation to improve mobility Improved only from 40 to 60 degrees of flexion Remains at Heartline PT ongoing 32

33 33

34 Open book pelvis (6.2 cm), R femur fracture, ~7 months pregnant 34

35 Right comminuted tib/fib with large open wound S/p open reduction, ex-fix placement, skin flap, skin grafting, and graft revision 35

36 Transferred back to Heartline 3-4 for prolonged IV antibiotics Ex-fix removal planned for late March Ongoing PT NGO with over 20 years in-country experience Extensive connections with other NGOs and community leaders Language and cultural expertise Large expatriate and Haitian staff already in place Strong connection to the communities (slums) we served, including strong security presence Significant monetary donations allowed 1-2 charter flights per week to bring in personnel, supplies, and medications for the first month after the quake Early focus on networking with multiple medical NGOs and the military to facilitate appropriate referral Frequent face-to-face contact to build relationships and trust Recognition that drivers, security, translators, and support personnel are just as vital as physicians and nurses State-side staff helped organize supplies and personnel Ongoing donations of time, money, medications, and supplies 36

37 Questions? (Later?) Beth McHoul Jen Halverson Troy Livesay Hughes Larosa 29/1/2010,USNS Comfort 37

38 Thank you for viewing this presentation To receive CME credit, please click the CME EVAL button below, and complete the form 38