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Haiti

Haiti, Patient Care, Pediatrics, Videos

Haiti earthquake relief by Packard Children's team

This new video from Lucile Packard Children’s Hospital shows footage shot by a team of doctors and nurses who went to Haiti Feb. 2 – 16 as part of the earthquake relief efforts. The caregivers traveled by boat to a remote village where most people had never been seen by a Western physician. They established a clinic now being run by other volunteers in the international relief effort.

The team, led by pediatric hospitalist physician Daniel Imler, MD, also included pediatric hospitalist Joseph Kim, MD, and nurses Rich Ramos, RN; Katie Purdy, RN; and Elena Hopkins, RN.

More coverage of the team’s trip to Haiti is available here.

Emergency Medicine, Global Health, Haiti, Stanford News

Haiti day 3: Amputees

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Bel Jean still hopes to be a priest. But there is a problem. “You need two arms to elevate the mass,” explains the 29-year-old, raising his stump in the air.

The young man (pictured above, left) was in Port-au-Prince studying for the priesthood when the earthquake struck on Jan. 12. During the night that he spent trapped beneath the roof of his school, he mostly cried. Then he prayed. The loss of his arm has him devastated. What he wants, though, is to replace his missing right arm with a new one so that he can hold high the sacrament during Sunday mass.

I’m in a ward at Paul Farmer’s hospital in Cange, a 2.5-hour bumpy car ride further north deep into the island nation from Hospital Albert Schweitzer in Deschapelles, where I have been staying the past few days. I’m traveling with members of the newly-formed rehabilitation team from HAS, to fit prosthetics for four of five of the amputees at Farmer’s hospital, which is similar in size and mission to HAS.

In a mad dash to begin to meet the overwhelming demand for artificial limbs in this country, where amputations have become the defining injury of the quake, HAS has quickly built a prosthetics lab, working with the Bethesda, Md.,-based Hanger Orthopedic Group Inc., a provider of prosthetic and orthotic products and services. The effort began 10 days ago. Within five days they had made 10 prosthetic limbs, and had five amputee patients up and walking.

Ian Rawson, who runs HAS, describes the situation during the earthquake on his blog:

Patients who arrived at HAS with crushing injuries to the extremities were managed by a specialized nursing wound care team, and the surgeons were very conservative in their management of these cases, exercising limb salvage strategies to the greatest extent possible. Only 15 long-bone amputations were required for the patients at HAS, but soon after the earthquake, we began to receive referrals from other hospitals for patients who required revisions of their original amputations.

HAS is an 80-bed hospital with an all-Haitian staff of 16 doctors and about 50 nurses. Today’s patient count hovers around 120 patients. Most of the amputees at the hospital are newly homeless. They’ll need to stay at least a week for fitting of prosthetics and then rehabilitation therapy to teach them to walk or to use their new prosthetic arms. Since most have no home to return to, the hospital is housing them at a place called L’Escale, a former tuberculosis village, a short walk past a village market from the hospital. Where they’ll go from there, no one really knows, but at least they’ll be able to walk away when they leave. Most will try to return to jobs in the fields or as laborers.

Estimates of crushing injuries that resulted in the emergency removal of limbs within the week after the quake range from 2,000 to 4,000. Eleven patients at the hospital are at some step of the limb making process right now. Today, the HAS rehabilitation team will add four more from Farmer’s hospital.

As the news gets out that HAS has perhaps the only functional prosthetics laboratory in the country – two were destroyed in Port-au-Prince during the earthquake – the demand is likely to spiral out of control. “Soon we’ll start to get people showing up at the hospital doors,” said Shaun Cleaver, one of two foreign-trained physical therapists in the entire country. He works at HAS. “It could get a little crazy.”
The rehabilitation team, including Cleaver and John “Jay” Tu, a prosthetist with the Hanger company, measure Bel Jean’s stump, then examine how well the stump has healed to determine if he’s ready for the casting process. That’s the first step. The cast will be taken back to the lab to create a mold that can be used to design a limb to fit the patient. Often the stumps of the earthquake victims have to be repaired surgically before being fitted because the initial operation was done under emergency situations in tents in the first few days after the quake.

“It was my last year in college to be a priest,” Bel Jean says. He shrugs. Now he doesn’t know what his future will hold. “You have to able to write if you’re a priest in Haiti, to run schools,” he explains. He lost the hand he writes with. His amputation is described as “above elbow.” The girl beside him is a double amputee, both “BK,” or below knee. The girl in the bed next to her is a single amputee, below knee. The plan is to transfer all three to HAS after their new limbs have been fabricated. They’ll stay there for the weeklong rehab process. After that, no one’s sure.

“I’m Roman Catholic,” Bel Jean says. “I used to love to see the Priest celebrate the mass when I was a child. I had one year left of school to become a priest.” He shrugs again and smiles. “Now, I don’t know.”

Tracie White is a Scope contributor and writer in the medical school’s communication office. She is presently in Haiti to write about the situation there. You can see all of her updates in our Haiti category. More details on Stanford’s Haiti relief effort are available here.

Global Health, Haiti, Stanford News

Haiti day 2: At the hospital

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I can bear the adult patients with amputated limbs, red and raw stumps oozing, waiting stoically on cots spilling out into the hallways. The toes missing from diabetes. The necks broken in motorbike accidents. But as the afternoon ticks by, the ages of the suffering in the Hospital Albert Schweitzer seem to get progressively younger, and the air grows increasingly heavy with heat and humidity and mosquitoes and despair. And my knees grow weaker.

It’s been a month and a half since the Jan. 12 earthquake killed 200,000 in Haiti and the initial trauma has passed, allowing the hospital staff to catch their breath as the thousands of refugees who rushed here from Port-au-Prince begin to disperse. The number of patients has dwindled from the peak of 800 down to 160, which is still twice the hospital’s normal capacity.

The families of the patients fill all the empty spaces of the hospital. They sleep on pads beneath the hospital beds. They wait in rows on hallway benches. In the courtyard outside the patient’s windows you can see them washing laundry and hanging it to dry on bushes and over railings. In the corridors, the smell of bouillon and Haitian stews further thicken the air. Mothers and grandmothers prepare lunch for their damaged children and their husbands and sisters and brothers.

It’s the questions of what to do with the amputees, and the paralyzed, and the homeless, that now hang heaviest in the air.

I’d been told repeatedly the Haitians are a resilient people. They’ve survivors. Some refused pain relievers in the operating tents in Port-au-Prince in the days following the earthquake. They don’t complain. “They’ve had so much thrown at them, they just get up and go,” explains one of the hospital doctors.

On my afternoon tour of the hospital on Friday, from the post-op ward to the pre-op ward to pediatrics, as the tragedies multiply, it’s this strength of the Haitian people that weakens me most.

The smile of the horribly burned teenage girl who we repeatedly pass in the hallway. The patient eyes of the young man holding the stump of his right leg in the air for the doctor to examine. The single mother of the young woman lying paralyzed in a hospital bed, holding her fifth child, a baby boy, in her lap and singing soft lullabies. And I can’t catch my breath.

The little girl with the orange ribbon in her hair that matches her orange socks. The teenage boy turning his back in a hospital corner to apply deodorant. Injured mothers nursing babies. A 5-year-old boy helping his horribly burned 2-year-old sister do her physical therapy.

The heat becomes nearly unbearable.

Finally at the end of the hallway, an adolescent boy, near my son’s age, allows the therapist to move his burned arm up and down, up and down, while smiling bravely to hide the guttural moans of pain that fill the room. And I turn away to hide my tears.

The patient above lost his leg and four fingers in the earthquake – he was studying at a professional school that collapsed and was one of the few survivors. His photo is published with his permission.

Tracie White is a Scope contributor and writer in the medical school’s communication office. She is presently in Haiti to write about the situation there. You can see all of her updates in our Haiti category. More details on Stanford’s Haiti relief effort are available here.

Global Health, Haiti, Stanford News

Haiti day 1: Arrival

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I took American Airlines flight #18 from JFK airport to Port-au-Prince on Feb. 24, only the second such commercial flight to land in post-earthquake Haiti since the Jan. 12 “Tremblement” that killed more than 200,000 Haitians.

My destination was Albert Schweitzer Hospital in Deschapelles, undamaged by the quake. It was overrun with refugees fleeing the 80 miles from the city of Port-au-Prince seeking medical help. They came by the hundreds, carrying their injured loved ones on the front doors from their fallen homes into the backs of pickup trucks to make the three-hour journey north into the mountains.

At its most crowded, the 80-bed hospital swelled to 800 patients – two days post-earthquake.

The passengers on the flight were, by far, of Haitian origin, with a few rescue workers dotting the aisles. Many were flying to Haiti for funerals. My seatmate’s brother-in-law was killed in Port-au-Prince. The man waiting in front of me to enter the plane was going to the funeral of a relative’s sister and her children. As we taxied out, a soft snow began to fall from the storm hitting the East Coast.

It was a quiet, somber crowd.

“It’s horrible, just gray,” said the Haitian flight attendant Monique, describing the view of Port-au-Prince from the air. She worked on the first New York to Haiti flight on American Airlines into the city. The airport had been closed to commercial air traffic for about a month after the earthquake left cracks in the walls of the main terminal building and toppled the control tower. It reopened after the U.S. military had taken over and repairs could be made.

Into the fourth hour of the flight, the mountains beyond mountains began to appear out the window – wave after wave of them, looking like the namesake of Tracy Kidder’s book Mountains Beyond Mountains, the biography of Paul Farmer. Then the city of 3 million, stretching from the harbors, covered the mountainsides. The damaged national cathedral and national palace jutted out from what must have been miles of brown and gray rubble. The USS Comfort, a massive ship where many earthquake victims were taken for surgery, stuck out like a white flag in the harbor.

My traveling companion, LeGrand Mellon, a 73-year-old New Yorker and sister-in-law of the hospital administrator at Albert Schweitzer Hospital, had traveled to Haiti on and off for years and was anxious to arrive, hoping to see Jackson, the armless porter who always carried her bags for a few bucks, and the Haitian band that routinely greets visitors as they step off the planes.

Part of the terminal was functioning when we arrived. The small Haitian band was playing when we stepped off the plane. Military trucks, soldiers with machine guns, crowds of white aid tents filled much of the airport grounds. We were shuttled to what was formerly a cargo hold, now temporarily a customs station. Luggage appeared, papers were stamped, all was orderly and well-mannered. Jackson, the porter, grabbed our bags with his good hand.

And then, there was Haiti.

Behind the bars that barricaded the airport, throngs of Haitians clamored, arms waving, teeth flashing, the native Creole filling the air (pictured at the top of this entry). The gates opened and Haiti rushed in.

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Women with chickens in baskets on their heads, lines of white U.N. trucks, Tap-taps (the brightly colored, overfilled Haitian taxis) bounced by. In bumper-to-bumper traffic and in the tropical heat, we navigated the streets on the outskirts of Port-au-Prince heading to the mountains, away from the tent cities made of sheets and tarps that lined the outskirts of town. Away from the vendors marketing bicycle pumps and juice boxes from wheelbarrows.

Soldiers with machine guns directed traffic (above, right). Sirens blared. A nun dashed by. An American tank rumbled by. Small boys with bundles of sugar cane to sell waved. Garbage littered the streets. The smell of charcoal from open fires filled the air.
“Isn’t this the greatest country in the world?,” said Mellon, grinning widely. “Oh, I’m so happy to be back.”

Tracie White is a Scope contributor and writer in the medical school’s communication office. She is presently in Haiti to write about the situation there. You can see all of her updates in our Haiti category. More details on Stanford’s Haiti relief effort are available here.

Global Health, Haiti, In the News, Stanford News

Stanford doctor discusses experience in Haiti

As previously reported, a team of Stanford physicians and nurses, including Paul Auerbach, MD, recently spent two weeks providing medical care to survivors of the Haiti earthquake. This morning, Auerbach was a guest on KQED’s Forum, where he discussed his experiences and the situation in the country. Audio from the live call-in show can be found here.

Previously: Treating the injured amid the apocalypse of Haiti and Stanford medical team returns from Haiti

Global Health, Haiti

Treating the injured amid the apocalypse of Haiti

Treating the injured amid the apocalypse of Haiti

Over the last two days, I have spoken to seven caregivers at Stanford who treated earthquake victims in Haiti, all describing what they experienced as life-changing and beyond anything they had witnessed before.

“It was a completely religious experience. It was an unbelievable outpouring of emotion and human bonding,” said Stanford orthopedic surgeon Gaetano Scuderi, MD. He jumped in to volunteer with a Haitian-American nonprofit group after seeing a CNN report of doctors abandoning patients because of security issues. He spent four days in a small village north of Port-au-Prince with 25 other physicians, treating as many as 800 patients with crushed and broken limbs and other traumatic injuries.

“I have to say we operated through tears in our eyes the whole time,” he said. The spirit of cooperation was so remarkable that only days into the relief mission did he discover that the person sweeping the floors in the tiny garage of an operating room was an oncology surgeon and chief of staff at a big Florida hospital.

“Everybody had one goal in mind. We knew people were out there dying. We didn’t want to waste a second.”

A separate team of Stanford emergency physicians and nurses also spent two weeks at the university hospital in Port-au-Prince, arriving to find a scene they described as “hell,” something out of an apocalypse. A sea of patients, some dead or dying, awaited them amid cries of pain and the overpowering smell of infection and death.

“Seeing those mangled extremities, the amputations and the infected wounds, it was overwhelming,” said Anil Menon, MD, a member of the team.

The group, which arrived Jan. 17 and was one of the first medical teams on the site, set up an effective system of care to triage and treat patients, trying to save as many lives as possible, said Robert Norris, MD, chief of emergency services at Stanford. They cared for an estimated 2,000 people in collaboration with other physician volunteers who arrived later on scene.

A podcast on the Stanford team’s experiences is available here.

Previously: Stanford medical team returns from Haiti

Global Health, Haiti, Stanford News

Health care in Haiti before the earthquake: A look back at Haiti's Albert Schweitzer Hospital

Even before last month’s earthquake, providing medical care in Haiti was a struggle. A 2002 Stanford Medicine magazine article describes the scene back then in one of today’s major sites for care in Haiti, Hôpital Albert Schweitzer. An excerpt:

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Chief operating officer Jackie Gautier, MD, a Haitian who formerly served as the hospital’s pediatric chief, announces that the hospital’s supply of post-anesthesia pain medications is used up with little likelihood it will be replenished in the next month or two.

“Why can’t you hand-carry some in on the next plane?” one physician asks. Gautier smiles thinly. Paperwork, not logistics, is involved, Gautier says diplomatically. Later, other physicians explain that while the hospital is entitled to import its supplies and medications duty free, the bankrupt Haitian government or an official might be waiting for an unofficial payment. In any case, the medication isn’t coming.

Today, the hospital, which is in a rural area outside of devastated Port-au-Prince, is serving as an “overflow valve” for those in need of medical care, says Stanford surgery professor Ralph Greco, MD, who has traveled there many times since the 1970s to work and train surgery residents.

More about what’s happening there day to day on the hospital’s blog.

Illustration by Stan Fellows

Global Health, Haiti

Rescuing Haiti's HIV/AIDS patients

Among the many aftershocks of the Haitian earthquake is that it left thousands of HIV/AIDS patients in dire need of medical help, including medication. Before the quake, Haiti was doing a credible job of caring for these patients, thanks to the efforts of a number of nonprofits, including Partners in Health and a clinic in Port-au-Prince known as Gheskio. But Gheskio, which cares for more than half of the country’s AIDS patients, was shattered by the temblor, and its operations have been thrown into chaos as a result of the catastrophe, according to a recent story in the Wall Street Journal.

One report in the New York Times described an AIDS patient, 38 years old and pregnant, wandering the street in search of help. She had walked three hours to a downtown clinic from a tent city in the slum of City Soleil. “Having missed an appointment the day after the earthquake, she had run out of pills and found herself racked by diarrhea and vomiting – on the streets, no less,” the Times reported.

Haiti has one of the highest rates of HIV outside sub-Saharan Africa, with an estimated 120,000 people living with the infection, according to UNAIDS. The prevalence rate among adults is 2.2 percent. Many of these patients are on antiretroviral treatment, but the rule of thumb is that these drugs have to be taken with clockwork regularity to remain effective. Patients who don’t follow a strict regimen not only leave themselves vulnerable to illness but are also at risk of developing drug-resistant forms of the virus. So making these drugs available to patients on a regular basis is critically important.

In response to the crisis, the Ford Foundation announced it will provide $250,000 to the Clinton Health Access Initiative to help maintain Haiti’s HIV/AIDS Services. The two organizations had been working in Haiti before the quake to strengthen the country’s HIV/AIDS programs. “HIV was a crisis in Haiti before the earthquake,” the foundation’s president, Luis Ubinas, said in a press release. “It is essential that HIV treatment is integrated into the crisis response. Emerging from this tragedy we have an opportunity, and a responsibility, to help build a strong and effective system of prevention and treatment that endures for the future.”

Global Health, Haiti, Stanford News

Reports from Stanford medical team in Haiti

Reports from Stanford medical team in Haiti

UPDATE JAN. 28, 2010: Paul Auerbach, MD, and Robert Norris, MD, have e-mailed a brief description of the medical and cultural experiences the Stanford team encountered while treating earthquake survivors in Haiti. The physicians’ letter is available here.

* * * *

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An eight-person team of Stanford physicians and nurses has been providing medical care to survivors of the Haiti earthquake as part of the larger International Medical Corps group. Three of those members have been blogging their experiences working in a Port-au-Prince clinic over the past 10 days.

The two physicians and nurse describe the widespread destruction, constant flow of patients and their frustration at not being able to do more. The reports are both horrific and hopeful.

Paul Auerbach, MD, who is pictured above watching Ian Brown, MD, perform a curbside sonogram, provides nearly daily progress reports of team operations on his Healthline blog.

Over the weekend he reported:

We saw a lot of progress today at the hospital. The surgeons are seeing a decrease in the number of patients that need emergency surgery for crush injuries and fractures, but that doesn’t mean that we are anywhere near a point where less-than-massive resources are needed. There are countless broken bones, deformities, facial injuries, burns and so forth, and we are encountering the sequelae of the initial surgeries that were performed in difficult settings. These mostly include infections that requires wash-outs of wounds and revisions of the prior surgeries. This is to be expected in our situation. The U.S. military has given the hospital tremendous report in facilitating the transfers necessary to the USS Comfort, which is thankfully still involved in this relief effort.

The hospital campus is evolving with some decent structure. We now have a central pharmacy, three operating rooms for adults, one operating theatre (within a tent, as are most facilities) for children, and arrangements for childbirth, children, postoperative patients, triage and emergency assessment, and so forth. These are crowded and extremely busy areas, staffed by dedicated physician, nurse and technician volunteers. We are moving toward 24 hour coverage. We have decent drinking water and food distributions. Phone lines will hopefully begin to come in tomorrow. We may soon have some reliable laboratory testing and do have a small blood bank.

There was great sadness and an unsettling moment as a body was recovered within our compound from under the wreckage of the nursing school. I have a fairly strong stomach, but had to walk away. There are perhaps many more bodies in that location. We lose an occasional patient now, and we are particularly saddened by the deaths of those we have come to know, and have tried unsuccessfully to save.

Anil Menon, MD, describes patient cases and daily life accounts through text messages, which are transcribed on a Healthline blog and on a friend’s blog. In a recent post he said:

Apparently, not everyone got hurt in the earthquake. I wouldn’t have known it from what I saw. A young kid was playing with his ball amidst the rubble and I realized that life moves on, no matter the magnitude of the problem. I’m worried that we will move on and forget the external fixtures that protrude from so many legs, or a nation full of amputees and without infrastructure.

Nurse Gaby McAdoo chronicles the treatment and recovery of a 5-year-old boy who was been trapped beneath a collapsed building for nearly eight days on her blog Out Of The Rubble Comes Hope.

Previously: Stanford sends medical team to Haiti
Photo by Chuck Liddy/The News & Observer (Raleigh, NC)

Global Health, Haiti, Mental Health

Next hurdle for Haitians: coping with PTSD

When I came across this ABC News article today on the emotional trauma being experienced by Haitian earthquake survivors, I immediately contacted David Spiegel, MD. The Stanford psychiatrist has done extensive research on post-traumatic stress disorder (PTSD), and I was eager to get his expert opinion on the situation in Haiti. Here’s our brief Q&A.

What do you expect we’ll see in terms of PTSD and depression among earthquake survivors?

There should be plenty of it. Virtually everyone was exposed to a life-threatening stressor (the earthquake and many aftershocks); many were injured or witnessed death or serious injury and now face threats to survival based on lack of food and water, disease, and violence. I would expect at least 1/4 of the population to have PTSD on that basis alone.

Then there are the many losses – home, possessions with memories attached, loved ones, work, neighborhoods, routines, lack of identification of bodies and proper burials – total disruption of personal and social networks, as well as injury and medical illness. Rates of depression increase with concomitant stressors, including medical illness, especially for people with a past history of depression or genetic vulnerability to it. And as the outlook for much relief gets grimmer, depression will increase. I would expect at least another 1/4 of the population to be depressed.

The ABC article notes that “months may pass before symptoms of PTSD or clinical depression emerge.” Does it typically take that long for symptoms to appear after a major event like this?

Yes, PTSD can emerge months later, and by our definition it cannot begin before a month after the initial traumatic stressor. Acute Stress Disorder can begin within two days of the stressor. Some hide symptoms as well, but even if careful diagnosis is done now (and it won’t be), more people will be affected over time.

Right now the focus in Haiti is on people’s basic needs. At what point should the focus turn to mental health?

Even now, behavioral problems are hampering the rescue efforts: violence breaking out around food distribution points, doctors withdrawing because security was not provided. Obviously, keeping people alive is paramount, but planning for emotional support and social organization will help survival. People with PTSD and depression are less likely to get needed food, water, and medical attention.

In terms of treating survivors with PTSD, what sorts of lessons have we learned from Hurricane Katrina and other major disasters?

High rates of PTSD in New York after 9/11 (12% throughout the city, 20% below Canal Street near the World Trade Center) resolved pretty quickly – about 6 months – largely because there was much emotional and social support, treatment was available, and people could resume their lives quickly. In New Orleans, the biggest long-term problem was depression, as people realized their city was pretty much lost, and it wasn’t coming back any time soon. The poor government response contributed, I think, to pervasive hopelessness and depression. I expect plenty of that in Haiti, since the goverment has all but evaporated.

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