Haiti earthquake - the medical challenges one month on

One month after the devastating earthquake struck Haiti, the numbers are still difficult to digest: it caused more than 200,000 deaths and 300,000 injuries.

Some of the first British doctors to arrive in the immediate aftermath have now returned home and explained what it was like treating victims of a disaster that overwhelmed an already strained medical system.

Paul McMaster, a retired surgeon from the West Midlands, and now surgical adviser to medical charity, Medicines Sans Frontiers (MSF), says his initial reaction on arriving in Haiti was of being overwhelmed by the extent of the devastation. But the emergency medical team very quickly began to focus on the casualties coming in. 

“Often there was a feeling of helplessness of wanting to do more and frustration because the equipment or material hadn’t managed to reach us. There were some upsetting procedures doing amputations under local anaesthetic, feelings were very strong.

“The surgery isn’t very complex, it is almost primitive, removing dead and damaged tissue and amputating limbs. For me it is always difficult having to amputate the limbs of children, already traumatised by their experience.”

He said the pace was non-stop during the first few days when casualties were pouring in. The surgical team was initially working off two makeshift tables in a courtyard under a tree, just going from one patient to the next. Although their equipment had not arrived they were able to borrow and make do with gynaecology instruments.

At first MSF teams were performing operations in the street, under plastic sheeting and in converted shipping containers. After a few days they were able to set up tented facilities near damaged buildings and imported an inflatable hospital with two operating theatres. Now MSF medical teams are working in more than 20 locations and running 10 operating theatres for major surgery and five for minor. 

In the past month MSF doctors have treated more than 18,000 patients and performed more than 2,000 surgical procedures. Some 1,400 tonnes of medical equipment and relief items have been delivered to the country and a further 350 tonnes of supplies are scheduled to arrive over the next few weeks.

McMaster says the saddest case that has stayed with him was not a casualty of the earthquake: “A baby came in with severe asthma complications we didn’t have the medication to treat her so the baby died. We didn’t know the baby’s name or where they were from or even whether the family knew the baby was dead,” he recalls.

Richard Villar, a consultant orthopaedic surgeon at the Wellington Hospital, London, who went to Haiti with the British charity Merlin (Medical Emergency Relief International) says at times he felt ineffective.  

In the first hectic days hospitals had either totally collapsed or were full. Surgical and medical teams worked around the clock in corridors, on landings, on the hospital steps, even in the car parks. Drugs and medicines were running out, single-use instruments being reused in sequential patients, gloves were being used for multiple cases, while amputations were performed in their hundreds on kitchen tables.

The emergency medical team sent to Haiti by Merlin operated in a field hospital nicknamed ‘Wimbledon’ as it had been set up on disused tennis court. Over the last month their medics have been performing up to 10 operations and seeing around 90 patients a day. Now the first wave of casualties has subsided teams are focusing on post-operative care, especially for amputees, to prevent infection and complications.

One extract from Villar’s field diary describes the chaos. “The clinic was chaotic today, patients jostling and queue-barging, everyone insisting they had to be first. The man whose head is still leaking cerebrospinal fluid from his skull fracture, the boy with the massive tumour in his neck, the child with the broken shoulder which has lain undiagnosed so far, the elderly lady with the broken sternum or breastbone and for whom every breath was agony. She had lain trapped for three days before rescue.

“Then there is the young girl with frequent blackouts since the earthquake who is claiming that a rock fell on her head at the time. I could find no evidence of damage, although that did not surprise me. This was manifestly post-traumatic stress, not the sole domain of the soldier.

“As a surgeon, I am unable to concentrate on any one task for long, as the moment I do, a hand touches me gently on the elbow to direct my attention to the next poor individual who has made their way to our clinic.

“The pattern of injury is now beginning to change. In the early days after the earthquake there were amputations by the hundred, head injuries and fractures. Now I am seeing many, many infections while tetanus, the scourge of contaminated wounds, has today arrived in Haiti.”

Villar says there were some uplifting stories of heroism: the man who held up a wall so his family could escape before the collapsing property crushed him dead.  There was also the husband who was forced to take a machete to his wife’s foot to release her from a pile of rubble. “How many of us react in such a circumstance? Not with such prompt courage, I would wager,” he suggests.

One of the more humbling aspects of the disaster was the huge level of support that Merlin was given. Villar says he also received considerable personal support from friends and colleagues around the world in the form of a dozen text messages or emails a day.

David Nott, a vascular specialist from the Chelsea and Westminster Hospital, London said the plight of injured children was the most heart wrenching aspect of his work in Haiti: “I find the whole experience extremely distressing, going round the wards, seeing children with amputated arms and legs screaming for their mothers and fathers when there are no mother and father because they have died in the earthquake. It’s one of the most emotional experiences I have ever had.” 

He became particularly attached to a three-month-old baby girl called Landina whose right harm had to be amputated. A patient in MSF’s Trinité hospital in Haiti before the earthquake, she sustained further injuries when the hospital building collapsed during the quake. In constant pain, she needed a titanium plate inserted into her skull. 

Initially Nott’s requests to move the child out of the country for specialist treatment were turned down by the US military authorities because of sensitivity over the security of Haitian children. But the authorities have since relented and this week Landina arrived in London for urgent treatment at the Great Ormond Street Hospital for Children.

Dr Nicola Cullum, an ST2 GP working in obstetrics and gynaecology at Colchester Hospital spent a week in Port-au-Prince, Haiti with the British charity called The Emergency Response Team (ERT).

Working in a field hospital based in the grounds of an existing hospital, in the heart of the city, close to the harbour, she says conditions were tough with a lack of basic necessities for patients such as access to clean water and enough food. There were no toileting/washing facilities available. Many of the patients’ families were also camping in the grounds after their homes had been destroyed. There were only two nurses for approximately 100 patients, so families were essential in helping provide care.

The team was faced with a lot of traumatic injuries such as fractures, cuts and burns. A week on from the earthquake, problems with infections were also common.

Cullum says there were many challenges: “We had a limited supply of medications and dressings with us, and although staff at the hospital were able to provide us with access to what they had it was still difficult to meet the demand. Many of the injuries needed surgical treatment that was simply not available.

“It was very difficult and at times upsetting, to be in a situation of not being able to provide patients with the proper treatment and care we knew they desperately required. There was no access to any radiological or laboratory investigations. An out-door operating theatre had been set up by a Cuban charity and they were able to perform a small number of amputations each day on badly injured patients.”

As aid started to arrive, some larger field hospitals were being set-up in the city. “Sadly it was nearly impossible to transfer seriously ill patients to them for further care as there was no ambulance service or transport, and no telephone contact with them to find out if they could accept patients or what facilities they had.

“Many of the roads were blocked and there were safety issues for rescue teams restricting movement around the city. For example, one day a search and rescue team brought in an elderly lady who had been found under the rubble of her home after seven days. She had a badly broken leg and was severely dehydrated. Our team did what we could to stabilise her condition and after several frustrating hours we managed to arrange for her to be evacuated to an American hospital, after a TV news crew agreed to take her in their vehicle.”

The search and rescue effort in Haiti was the largest ever international operation of its kind. Cullum says she found it inspiring seeing teams from all over the world all working together with the aim of helping Haiti’s people.

Four weeks after the earthquake struck Haiti the first phase of the disaster of dealing with the dead and severely injured is coming to an end.

But the next phase promises to be as cruel as the first, with further deaths likely to occur due to exposure, starvation, and infectious diseases.

Millions of Haitians are homeless and have no food, clean water, sanitation, or primary health care. And the rainy season is coming. Many Haitians now need psychological support to help deal with the after effects of serious injury, grief and displacement.

“For the survivors of this disaster there will be a great need for medical support and humanitarian assistance for many months and years to come,” says Cullum.

For further information about the ongoing relief operation in Haiti visit: ERT; MSF; and Merlin.

Tags: Disaster relief, Haiti