Perspective

Rapid Medical Relief — Project Medishare and the Haitian Earthquake

Enrique Ginzburg, M.D., William W. O'Neill, M.D., Pascal J. Goldschmidt-Clermont, M.D., Eduardo de Marchena, M.D., Daniel Pust, M.D., and Barth A. Green, M.D.

N Engl J Med 2010; 362:e31March 11, 2010

Article

On the evening of January 12, 2010, a few hours after the Haitian earthquake, the leaders of Project Medishare in Miami began contacting Haitian associates, faculty and staff of the Miller School of Medicine at the University of Miami, and owners of small private jets in southern Florida. Project Medishare is a nonprofit nongovernmental organization created in 1995. Given our geographic proximity to Haiti and our 15-year relationship with Haitian physicians through Project Medishare, we were able to offer emergency medical relief and provide medical staff within 20 hours after the earthquake. A five-person team of medical relief workers arrived at the Port-au-Prince airport on January 13. They were presented with 225 severely injured Haitians housed in two open storage tents at the United Nations compound at the airport (see photoTurning a Storage Tent at the United Nations Compound into an Emergency Room.). The injuries included open and closed long-bone fractures, suspected pelvic and spinal fractures, complex open wounds, and crush injuries, as well as severe dehydration. Approximately 30% of the casualties were infants and children.

The only medical supplies were those brought by the initial corporate jet. On day 1, the overwhelming need was for intravenous hydration, narcotic analgesics, and casting supplies for the splinting of fractures. Two patients died that day from severe respiratory distress, presumed to be caused by fat emboli.

On day 2, a second group of staff members that included an internist, pediatricians, and nurses, several of whom spoke Creole, arrived. They brought intravenous fluids, angiocatheters, ketamine, fentanyl, and narcotics. Intravenous volume resuscitation was administered to — and stabilized — many severely dehydrated patients. Working with no clinical laboratory testing, the teams monitored fluid resuscitation by means of physical examination and urine output with Foley catheters (and suprapubic catheters for patients with pelvic fractures and spinal injuries). Two patients with impending gangrene required amputations (one arm, one foot). Operations were performed with moderate conscious sedation on a table outside the tents.

By day 4, anesthesiologists with expertise in regional anesthesia, as well as pediatric and adult orthopedic surgeons, had arrived at the site. A provisional operating room was created in a partitioned and enclosed section of one of the tents (see photoSurgeons Operating in a Partitioned Section of a Tent at the United Nations Compound.). Because of the irreversible open crush injuries to limbs, many patients were becoming septic and their limbs gangrenous. Compartment syndromes were also common. For these reasons, 12 operations were performed, including 9 amputations and 3 open débridements and fasciotomies. On day 5, five patients died, four from sepsis and one from renal failure owing to rhabdomyolysis from a severe crush injury. Continued sepsis was addressed not only with a more aggressive surgical approach (open débridements and amputation of nonsalvageable limbs) but also through a change in antibiotic strategy. At first, the only available antibiotics were cefazolin and vancomycin. On day 4, new antibiotics arrived from Miami. Because the teams were working without a microbiology laboratory and believed that wider-spectrum antibacterial coverage was required to treat highly contaminated open wounds, many patients with impending sepsis were switched empirically to piperacillin and tazobactam. With this strategy, the condition of many patients with impending sepsis stabilized and improved, and we lost no further patients from sepsis. No patients who were brought to our site for initial care contracted tetanus, probably owing to our policy of immediate treatment with toxoid on admission.

On day 5, the teams performed 15 operations, 12 of them amputations. On days 6 and 7, when 31 surgeries were performed, only 3 amputations were required.

Daily flights of small jets, which were coordinated by a rapidly assembled command center in Miami, shuttled between Miami and Port-au-Prince during the first week, bringing additional medical relief workers and supplies. By the end of the week, we had assembled a standing team of more than 100 volunteers to care for an ever increasing number of injured people. Small commercial jets handled sporadic evacuations of severely injured patients — including those with pelvic fractures and spinal injuries — as well as pediatric patients, to Martinique and later to the United States. A few patients were transferred to a nearby Israeli army field hospital that had functional respirators.

It was quickly apparent that the United Nations compound was inadequate as a field hospital. Four days after the earthquake, a group of volunteer medical staff members and hospital administrators began to plan and assemble our new field hospital — four event tents erected on the airport grounds (see photoConstruction of the University of Miami Field Hospital.). On January 21, the University of Miami Hospital Haiti opened, and all patients were transferred to it.

The Haitian relief effort was hampered by the total devastation of the country's medical infrastructure. After the earthquake, there were only two functioning operating rooms in Port-au-Prince. Air evacuation of severely injured patients was initially extremely limited. An alternative model for immediate relief was required.

Our experience indicates that small, correctly staffed and equipped teams arriving in small jets and with knowledge of the region can provide effective first-response medical care in remote locations within hours after an earthquake. A command center that can organize and supply needed volunteers and needed supplies as conditions change at the disaster site is key. For the first 48 hours, intravenous hydration, wound dressings, orthopedic splints, tetanus toxoid, and narcotic analgesics will stabilize most injured patients whose lives can be saved. Our experience suggests that persons with severe thoracic or abdominal crush injuries do not survive.

By 72 hours, we began to see deaths from sepsis. Open wounds that had not been sufficiently treated resulted in wet gangrene. To contain the situation, we used an aggressive strategy, with amputations of irreversibly injured limbs, open surgical débridement of wounds, and the administration of broad-spectrum intravenous antibiotics. Regional anesthesia with conscious sedation was essential, given that we had no oxygen, ventilators, or monitors. Once surgery could be performed more routinely, the need for general anesthesia increased. With the availability of general anesthesia came the need for self-contained oxygen-generation units, given the lack of sufficient oxygen tanks.

In our experience, initial medical responders should include orthopedic surgeons, trauma surgeons, wound-care specialists, anesthesiologists, and infectious-disease physicians. Pediatricians, pediatric surgeons, and pediatric orthopedic surgeons will be needed to deal with the large percentage of pediatric injuries. Clearly, much of our group's success was due to the dedicated care provided by our volunteer nurses. It is also essential to have native speakers among the care providers to communicate with patients and families.

The University of Miami Miller School of Medicine–Project Medishare medical relief project treated 425 severely injured, immobile survivors in the first week after the Haitian earthquake. Our experience suggests that rapid response can be highly effective.

Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.

This article (10.1056/NEJMp1002026) was published on February 24, 2010, and was updated on February 25, 2010, at NEJM.org.

Source Information

From the Departments of Surgery (E.G., D.P.), Medicine (W.W.O., P.J.G.-C., E.M.), and Neurosurgery (B.A.G.), Leonard M. Miller School of Medicine, University of Miami, Miami.

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