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Annals of Internal Medicine
An Academic Center’s Delivery of Care After the Haitian Earthquake
Amir K. Jaffer, MD; Rafael E. Campo, MD; Greg Gaski, MD; Mario Reyes, MD; Ralf Gebhard, MD; Enrique Ginzburg, MD;
Michael A. Kolber, PhD, MD; John Macdonald, MD; Steven Falcone, MD, MBA; Barth A. Green, MD; Lazara Barreras-Pagan, RN, BHSA;
and William W. O’Neill, MD
The Miller School of Medicine of the University of Miami and
Project Medishare, an affiliated not-for-profit organization, provided
a large-scale relief effort in Haiti after the earthquake of 12 January
2010. Their experience demonstrates that academic medical centers
in proximity to natural disasters can help deliver effective medical
care through a coordinated process involving mobilization of their
own resources, establishment of focused management teams at
home and on the ground with formal organizational oversight, and
partnership with governmental and nongovernmental relief agen-
cies. Proximity to the disaster area allows for prompt arrival of
medical personnel and equipment. The recruitment and organized
deployment of large numbers of local and national volunteers are
indispensable parts of this effort. Multidisciplinary teams on short
rotations can form the core of the medical response.
T
and a simple intensive care unit), supply storage, and staff
quarters. Other supplies were airlifted from Miami several
times daily. Approximately 140 patients from our first facility were transported to the new hospital on 21 January
2010.
Staffing of the hospital was accomplished almost
exclusively through volunteers who signed up for 5- to
7-day deployments. A travel clinic was set up in Miami
to provide counseling for deploying volunteers, and a
Web-based survey for returning volunteers was used to
assess their adherence to malaria prophylaxis and to determine whether referrals for medical or psychological
issues were needed.
To coordinate efforts, we created under the supervision of a chief medical officer an organizational structure
that mirrored our hospital structure in Miami but also
addressed Haiti-specific issues. Because of the massive
damage to the communications infrastructure, we set up
satellite links for telephone and Internet connections. The
command groups in Haiti and Miami had joint conference
calls every morning, during which the day’s goals and plans
were determined.
he 12 January 2010 earthquake in Haiti, one of the
worst natural disasters in the past 2 centuries, left
230 000 dead and 1.5 million homeless. Given the University of Miami’s proximity to Haiti and a 15-year relationship with Haitian physicians through Project Medishare, a not-for-profit health care organization set up by
Miller School of Medicine faculty, the university was able
to offer emergency relief within 20 hours after the earthquake. We have previously described our experience during
the week after the earthquake (1). Here we describe the
University of Miami Hospital in Haiti, a field hospital that
began functioning at the Port-au-Prince airport 8 days after the earthquake (Figure 1).
ORGANIZATION OF SYSTEMS, TEAMS,
FIELD HOSPITAL
AND THE
Given the magnitude of the relief effort, it immediately became apparent that logistic organization would be
as challenging as delivering care. Critical needs were obvious: coordination of flights from Miami into a damaged
airport; provision of guidance regarding medical precautions for hundreds of volunteers; and transportation of
massive amounts of medical supplies, food, and water. We
quickly established an organization table to keep track of
multiple aspects of the operation (Figure 2) and put together a coordinating center housed at our Miami campus.
Our initial hospital was a small facility within the
United Nations compound that we rapidly outgrew (1).
The second hospital was constructed in 4 days after flying
in 2 electric generators, construction equipment, and 4
air-conditioned tents from Miami: one tent each for a pediatric ward and an adult ward (with 4 operating rooms
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CLINICAL CARE
AND
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COORDINATION
Because of limited resources and the large number of
patients in need, medical and surgical triage was of paramount importance. On arrival, patients were triaged by an
internist or a pediatrician, and then an appropriate surgeon
(trauma, orthopedic, or neurosurgery) developed a plan of
care. Many of our nursing and medical staff were of Haitian origin and spoke Creole. Family members helped in
caring and feeding patients.
Limbs with gross infection and impending sepsis or
compromised vascular flow had emergent guillotine amputation and staged debridement after 3 treating surgeons
concurred and patients gave written consent through a
Creole interpreter. No amputation was closed before the
third debridement. Open fractures were scheduled for repeated debridement every 2 to 3 days. There was a low
262 © 2010 American College of Physicians
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An Academic Center’s Delivery of Care After the Haitian Earthquake
threshold for repeated operative debridement. Intraoperative fluoroscopy permitted application of external fixators
when appropriate. Because of the challenging field conditions, we chose not to undertake internal fixation. Patients
requiring this were transferred to the USNS COMFORT or
the United States. More than 203 surgical procedures were
performed between postearthquake days 4 and 12.
We treated 48 chronic compartment syndromes by
postearthquake day 12. On postearthquake day 10, we acquired a digital radiography machine and casted nearly all
closed ankle, tibia, wrist, and forearm fractures (more than
98 in 3 days). Best attempts were made at closed reduction
by orthopedic surgeons. The need for a wound care team
became apparent—approximately 80% of patients had
open wounds. Our wound care program consisted of both
adult and pediatric bedside teams for dressing changes that
were equipped to handle major debridement and vacuumassisted closure application with conscious sedation.
Patients requiring surgical intervention in the immediate aftermath of an earthquake frequently have extremity
injuries that are challenging in anesthetic management, because many individuals develop hypovolemia, sepsis, electrolyte, and coagulation disturbances (2, 3) that can complicate general and neuraxial anesthesia. Peripheral nerve
blocks have a favorable safety profile and provide adequate
anesthesia independent of oxygen supplies and electricity
and, if necessary, with only limited monitoring. Therefore,
most surgeries were performed under local peripheral nerve
blocks, and only some complex surgical cases were performed under general anesthesia.
Perspective
Figure 1. Aerial view of University of Miami Hospital,
Port-au-Prince, Haiti.
Arrow A is the location of the operating room in the posterior part of the
first tent. Arrow B is where the wound center was located. Arrow C is the
triage area. Arrow D is the second triage tent, where the pediatric patients were admitted. Arrow E is the tent where staff and health care
workers were housed. The supplies tent is to the left but is not included
in the photograph.
Internists, pediatricians, and hospitalists focused on
the medical management of surgical patients (for example,
fluid and pain management and thromboembolism prophylaxis) and were responsible for the logistic aspects of
organizing and running the hospital. Infectious diseases
specialists helped select antibiotic regimens from a simple
yet robust antimicrobial formulary. Combined medical-
Figure 2. Organization of the team at the command center in Miami.
Chief Medical Officer
Chief Administrative Officer
Security/
Facilities/
IT/Telecom
Lead
Personnel and
Flight Logistics
Lead
Rotation
Material
Donations
Lead
Fundraising
Telecom,
Facilities
Coordinator
Material
Donations
Lead
Fundraising
Telecom
Coordinator
Fundraising
IT
Coordinator
Grant writer
IT
Coordinator
Finance
Fundraising
Finance
Airport Ramp,
Warehouse, and
Transportation
Lead
Supply
Chain
Lead
Coordinator
Coordinator
Coordinator
Nonmedical
Supplies
Public
Relations/
Communications
Lead
Medications
Consultant
Airplane
and Flight
Slots
Office
Manager/
Manifest/
Volunteer
Coordinator
Information
Line
Information
Line
Receptionist/
Information
Line
Volunteer
Spreadsheet
Teams were created with a lead person responsible for each team, including finance, fundraising, IT, security, personnel and flight logistics, material
donations, airport operations, supply chain, public relations and communications, and volunteers. IT ⫽ information technology.
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Perspective
An Academic Center’s Delivery of Care After the Haitian Earthquake
Figure 3. Initial presentation and radiographic diagnosis of a
pelvic fracture.
were ready for discharge. The organization of the pediatric
ward mirrored that of the adult ward.
Besides operative capability, the inability to perform
radiography and fluoroscopy when the focus was on managing crush injuries and fractures presented a major challenge. Portable digital radiography and fluoroscopy units
were not available for about 10 days. Figure 3 highlights
the initial clinical impression of a pelvic fracture that was
confirmed when radiography became available. Radiography technicians were always in short supply, and physicians were trained to use the machines by the technicians
and the manufacturer’s representatives, who flew to Haiti
to provide training. Patients who could not be appropriately cared for at our hospital were transported to the Israel
Defense Forces Medical Corps Field Hospital or the USNS
COMFORT; some were flown to the United States in a
military plane.
Many of our health care workers had clinically significant emotional stress. Our psychiatry department dispatched personnel with experience in supporting health
care workers involved in disaster relief, and we encouraged
volunteers to pair up and monitor each other’s stress.
LESSONS LEARNED AND APPLICATION
RESPONSES TO DISASTERS
Top. Initial presentation documents the initial impression for an earthquake victim admitted on 13 January 2010. Bottom. Radiographic diagnosis confirms the initial impression of pelvic fracture 9 days later on
plain radiographs.
surgical rounds were held at least once daily, with the objective of establishing a joint plan of care and identifying
cases that needed surgical or radiological procedures or
TO
FUTURE
Our university had never been involved in disaster relief of this magnitude. Aspects of our response that did not
go as well as we would have hoped included our lack of
adequate interaction early with the United States Southern
Command based in Doral, Florida (which is responsible
for U.S. military operations in South and Central America). Early interaction would have allowed us set up early
communications between Haiti and Miami and to better
procure and allocate personnel and supplies. Inclusion of
immediate first responders who were fluent in Creole
would have been most helpful.
It also took several days to create an organizational
structure for the disaster response de novo. On the basis of
our experience, we believe the highest priority should be
placed on putting an organizational structure in place at
the local institution that is preparing to respond to a natural disaster. This structure should reflect aspects of the
operation that are necessary on the ground in the foreign
country and at home.
We had a difficult time securing voluntary radiography technicians. Soliciting help early from national
professional organizations, such as the American Society
of Radiologic Technologists, might have prevented this
limitation. Immediate creation of a Web-based document
that specified medical needs for travel to the area (for example, immunizations and travel documents) and reflected
what volunteers should expect to encounter would have
been helpful. Preparedness counseling and planned postexposure counseling to deal with posttraumatic stress disorder should have been put in place immediately.
264 17 August 2010 Annals of Internal Medicine Volume 153 • Number 4
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An Academic Center’s Delivery of Care After the Haitian Earthquake
Despite the limitations and gaps we have outlined, we
feel our intervention was successful and that universitybased medical health care systems can play an important
role in disaster relief. Our prior relationship with Project
Medishare highlights the benefit of academic health centers
having established relationships with foreign countries on
which disaster response can be built. The critical and core
elements of our response included prompt organization of
teams and systems both in Miami and in Haiti, communication between personnel in Miami and Port-au-Prince
on a scheduled and ongoing basis, deployment of shortstay medical volunteer teams, prompt transportation of essential supplies and equipment, and construction of a simple yet robust field hospital. The early phase of medical
care delivery was focused on managing trauma. Very simple radiology equipment proved indispensable for the management of orthopedic trauma. Laboratory support was absent initially; however, many patients were successfully
managed initially with clinical examination alone. Our experience and the lessons learned can be applied by medical
centers and organizations interested in delivering emergent
trauma care during future natural disasters.
PERSONAL ARCHIVES
Perspective
From University of Miami Miller School of Medicine, Miami Children’s
Hospital, University of Miami Sylvester Comprehensive Cancer Center,
and University of Miami Health System, Miami, Florida.
Potential Conflicts of Interest: Disclosures can be viewed at www.acponline
.org/authors/icmje/ConflictOfInterestForms.do?msNum⫽M10-0807.
Requests for Single Reprints: William W. O’Neill, MD, University of
Miami Health System, 1600 Northwest 10th Avenue, RMSB 1122A,
Miami, FL 33136; e-mail, [email protected].
Current author addresses and author contributions are available at www
.annals.org.
References
1. Ginzburg E, O’Neill WW, Goldschmidt-Clermont PJ, de Marchena E, Pust
D, Green BA. Rapid medical relief—Project Medishare and the Haitian earthquake. N Engl J Med. 2010;362:e31. [PMID: 20181963]
2. Mulvey JM, Awan SU, Qadri AA, Maqsood MA. Profile of injuries arising
from the 2005 Kashmir earthquake: the first 72 h. Injury. 2008;39:554-60.
[PMID: 18054014]
3. Yang C, Wang HY, Zhong HJ, Zhou L, Jiang DM, Du DY, et al. The
epidemiological analyses of trauma patients in Chongqing teaching hospitals following the Wenchuan earthquake. Injury. 2009;40:488-92.
[PMID: 19328487]
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Current Author Addresses: Dr. Jaffer: Department of Medicine, University of Miami Miller School of Medicine, 1120 Northwest 14th
Street, 933 CRB (C216), Miami, FL 33136.
Dr. Campo: Division of Infectious Diseases, University of Miami Miller
School of Medicine, Clinical Research Building, 1120 Northwest 14th
Street, Room 855 (R-21), Miami, FL 33136.
Dr. Gaski: Department of Orthopedics, University of Miami Miller
School of Medicine, PO Box 016960 (D-27), Miami, FL 33101.
Dr. Reyes: Division of Pediatric Hospitalists and Pediatric Advance Care
Team (PACT), Miami Children’s Hospital, Main Building, Third Floor,
3100 Southwest 62nd Avenue, Miami, FL 33155.
Dr. Gebhard: Department of Anesthesiology, University of Miami
Miller School of Medicine, 1611 Northwest 12th Avenue, Room C-302,
Miami, FL 33136.
Dr. Ginzburg: Department of Surgery, University of Miami Miller
School of Medicine, 1800 NW 10th Avenue, Miami, FL 33136.
Dr. Kolber: Division of Infectious Diseases, University of Miami Miller
School of Medicine, Clinical Research Building, 1120 Northwest 14th
Street, CRB 859, Miami, FL 33136.
Dr. Macdonald: Department of Dermatology and Cutaneous Surgery,
University of Miami Miller School of Medicine, RSMB Room 2023,
Miami, FL 33136.
Dr. Falcone: University of Miami Miller School of Medicine, 1150
Northwest 14th Street, Suite 701, Miami, FL 33136.
Dr. Green: Department of Neurologic Surgery, University of Miami
Miller School of Medicine, Lois Pope Life Center, 2nd Floor, 1095
Northwest 14th Terrace (D4-6), Miami, FL 33136.
Ms. Barreras-Pagan: University of Miami Sylvester Comprehensive Cancer Center (D-1), 1475 Northwest 12th Avenue, Suite 4037, Miami, FL
33136.
Dr. O’Neill: University of Miami Health System, 1600 Northwest 10th
Avenue, RMSB 1122A, Miami, FL 33136.
Author Contributions: Conception and design: A.K. Jaffer, R.E.
Campo, M. Reyes, M.A. Kolber, B.A. Green, L. Barreras-Pagan, W.W.
O’Neill.
Analysis and interpretation of the data: A.K. Jaffer, R.E. Campo, G.
Gaski, J. Macdonald.
Drafting of the article: A.K. Jaffer, R.E. Campo, G. Gaski, M. Reyes, R.
Gebhard, E. Ginzburg, M.A. Kolber, S. Falcone, W.W. O’Neill.
Critical revision of the article for important intellectual content: A.K.
Jaffer, R.E. Campo, R. Gebhard, S. Falcone.
Final approval of the article: A.K. Jaffer, R.E. Campo, M. Reyes, E.
Ginzburg, M.A. Kolber, J. Macdonald, L. Barreras-Pagan, W.W.
O’Neill.
Provision of study materials or patients: B.A. Green, L. Barreras-Pagan.
Administrative, technical, or logistic support: R. Gebhard, L. BarrerasPagan, W.W. O’Neill.
Collection and assembly of data: A.K. Jaffer, R.E. Campo, G. Gaski, E.
Ginzburg, M.A. Kolber, L. Barreras-Pagan.
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