The “lessons learned” that are discussed in the following article were developed primarily from the relief mission to Haiti that was organized by Mount Sinai Hospital in New York City, which responded with the support and affiliation of the NGO Partners in Health. The goal of the article is to reinforce, for other organizations and individuals, lessons that can be used in future humanitarian responses carried out by private hospitals and/or teams of medical volunteers.
Less than two months ago – more specifically, on 12 January 2010 – the earth shook in Port au Prince, Haiti, and for millions of Haitians the world was forever changed, in less than a minute. The magnitude 7.1 earthquake revealed to the world not only how poor the population of Haiti was, and is, but also how tenuous the Haitian healthcare system was even before the disaster.
Relief organizations all over the world mobilized their staffs, and their members, to send help almost immediately. Numerous government agencies and organizations, as well as non-government organizations (NGOs), put together relief efforts to focus on the immediate needs of water, food, rescue, and eventually emergency health care. The health care response would have to be geared to a region that was considered, even before the quake, to be probably the poorest in the Western Hemisphere. It has been estimated that approximately 110,000 Haitian adults are living with HIV/AIDS. A host of other deadly and/or debilitating diseases – e.g., malaria, dengue fever, parasitic infections, hepatitis, typhoid fever, and rabies – were not uncommon in Haiti even prior to the quake. These facts took a back seat, though, to the immediate need for medical personnel to respond to a mass-casualty disaster of staggering dimensions.
The response by American physicians, nurses, and other medical professionals has been well documented in the U.S. news media. During the first ten days after the quake many American medical personnel and organized relief missions arrived in Port au Prince. What happened before the medical teams, and the supplies and equipment they brought with them, arrived in Haiti is still a relatively unknown story.
The Pre-Planning Stages
Even though most relief organizations started to plan immediately, because of the severe need for doctors and nurses, it was important to focus closely on the specific types of help that would do the most good for the most people. The extreme need for surgeons, and for a well organized pre- and post-operating system, was acknowledged by several NGOs that were already on the ground in Haiti and providing healthcare even before the earthquake. Responders were able to obtain valuable information from those agencies on the specific personnel needs and the medical equipment also required – for amputations, for example, for open & closed extremity fractures, and for infections.
Aligning the response with such organizations turned out to be an invaluable help. There were, and are, numerous reports of physicians who self-deployed only to quickly become frustrated, and sometimes fearful for their lives as well, because of the support they were not receiving during their first 24-48 hours in-country. Many medical personnel and small groups even left Haiti with a high degree of frustration in not having been put to use. A key lesson learned by the Mount Sinai group from this difficult situation was the need for the volunteers themselves – individuals as well as small groups – to be as self-reliant as possible for at least the first 48 hours in-country.
The NGOs that responded, and stayed, were recognized as doing an almost unbelievable job in setting up systems for healthcare in a relative vacuum. Taking care of the responders’ own needs, though – for food, water, transportation, shelter, and security, to name just a few of the more obvious requirements – was proving to be a massive task secondary only to helping the sick and injured Haitian citizens.
Volunteers from U.S. healthcare institutions were not totally naive in their response to the Haitian disaster, of course, but in retrospect it seems obvious that relying immediately, and directly, on an NGO for the everyday necessities of life was somewhat unrealistic, given the almost total lack of infrastructure in the Haitian capital (and in the areas just outside Port au Prince).
The groups that responded (this experience is based primarily on reports from the medical teams based in and around the National Hospital-HUEH) to several NGOs all seemed to experience more or less the same needs and frustrations during the initial 24-48 hour time frame. There was no reliable source of uncontaminated food and water, and shelter from the elements was minimal at best – one medical group slept in tents close to the runway of the city’s main airport, and others slept on concrete floors in the hospital itself. Perhaps the most problematic issue, though – partly because of the looting and general public disorder that followed the quake – was finding safe transport, through the devastation, to and from the hospital each day.
These and other needs were eventually responded to (successfully, for the most part) by the NGOs, and/or by the various official government organizations and agencies – specifically including units of the nation’s armed services – that arrived in-country as more time passed. However, although some rescuers could and did manage to put up with the squalid, and dangerous, conditions they encountered, many others were definitely not prepared. If civil unrest had gotten worse, or if the weather conditions were poor, or if an infectious outbreak of a lethal disease had occurred and rapidly spread, the difficult task of coordination would have been much more dangerous as well for the responders and rescuers themselves.
Mount Sinai Experience Pays Off
The Mount Sinai Team response was about as well formulated as it possibly could be during the three days of pre-planning that preceded the first flight to Haiti, particularly given the meager intelligence that was available (but was frequently either outdated or incomplete or actually erroneous). A 27-member surgical team – made up primarily of surgeons, anesthesiologists, nurses, nurse practitioners, surgical technicians, and administrative/logistical support personnel – was formed in relatively short order, and a team organization was developed with leadership roles assigned to specific physicians, nurses, administrators, and team coordinators.
The Mount Sinai Hospital Incident Command System (HICS), which had been activated to coordinate the team development, was found to be extremely valuable, particularly in such tasks as: the detailed screening of volunteers; meetings with the hospital’s legal department (to get answers on liability); other meetings with representatives from human resources (to determine compensation requirements); the logistical coordination of the supplies needed and/or available; and travel information, including the determination of immunization requirements.
All volunteers were briefed on the information received from the NGOs, and from government organizations and agencies already on the ground in Haiti. However, the volunteers were given less than 24 hours to obtain the passport information they needed, the immunizations required, and the prescriptions that had to be filled prior to travel. One particularly valuable lesson learned came from recruiting team members who spoke Creole or French (Haitian volunteers were seen as a plus for many reasons; this was one of them).
Team members were asked: (a) to bring with them only one bag for their clothing and other personal items; and (b) to plan to stay for two weeks, but possibly longer. It was not known in the initial planning stages when and/or how the volunteers would return to their home communities.
A private charter flight would be the method of transport, but because of the very tight time frame that had been set the aircraft’s capacity was not known until 24 hours before the flight. The cargo capacities planned, in both size and weight, were estimates at best, so the supply list was developed with minimal and, as it turned out, inadequate information. More than 4,000 pounds of equipment, not counting personal baggage, was brought to the plane before it was realized that only about 3,000 pounds of supplies, including personal luggage, could be taken on the initial flight. A quick “triage” of the most important supplies and equipment was carried out at the plane itself, and each box was labeled and weighed. Nonetheless, and despite this unexpected difficulty, it was obvious that the pre-planning activities were an invaluable help in quickly loading the plane and meeting the necessarily very tight landing schedule.
During the next eight days the Mount Sinai Relief Response – which included volunteers from other New York City Hospitals (Elmhurst, Queens General, Mount Sinai Queens, Beth Israel, and Maimonides) – developed a functional operating suite where the volunteers carried out and/or assisted in over 120 surgeries, organized equipment/sterilization processes, developed pre- and post-anesthesia patient care, carried out their daily “rounds” (checking vital signs and changing bandages) on all patients presenting themselves for care, and established a logical and cohesive system for documenting the surgical care that had been provided.
Lessons Learned – And Daily Reinforced
There are hundreds of stories on how the medical mission in Haiti affected the patients and medical staff. Possibly the principal lesson – reinforced, and visible in the faces of many volunteers who were in Haiti during the first 24-48 hours – was, and is, the disorientation that exists in such a country, in such circumstances. Becoming self-sustainable for basic needs is very important, therefore, if only because the NGOs that volunteers may be relying on might well be busy with other tasks of higher priority. The nation’s Disaster Medical Assistance Teams (DMATs) have learned, over many years of deployments, that the teams should come into a disaster scene ready to take care of themselves for at least the first few days, and possibly longer.
Developing a team approach and organization in advance was invaluable in the effort to quickly develop a medical group and ensure a successful mission. Other lessons learned focused on the importance of team meetings, the reinforcement of safety/situational awareness, and setting up teams in pairs – with easy-to-remember meeting places (where individual volunteers could go if safety issues arise). The safety issues cannot be emphasized enough, especially in countries such as Haiti, where there is little or no information available about areas of civil unrest.
The pre-planning for infection protection of volunteers who wanted to deploy also was important. Immunizations and prophylactic medicines are needed so that the volunteer staff feels both safe and protected. Certain personal medications (for malaria and HIV, for example) may have to be started before departure – and continued after the mission is over – to protect volunteers. This information needs to be strongly reinforced, particularly given the infectious-disease history of the area and especially the potential for lethal outbreaks during and after a major disaster.
Precautions related to blood and other body fluids also became very important to reinforce (Mount Sinai brought its own prophylactic HIV kits for needle stick precautions) during long operations and/or when staff became tired.
There also were a number of mental health concerns – caused by, among other things, the difficult emotional experiences, the strange and dangerous environment, the lack of food and/or water, or simply the fact that the volunteer is away from his or her family, and isolated to some degree. Many such issues, with mental as well as physical causes and symptoms, should be a conscious concern of all volunteers. The use of informal debriefings during and at the end of such experiences can be of help even for those who may have served on similar missions in the past. Support at home is also important so that volunteers know their families are aware that they are safe (a nightly briefing was carried out by Mount Sinai, which sent family emails out every day).
Simple personal supplies are among the small necessities that many volunteer responders may not think of until they are actually on-scene in a disaster area. Items such as Vick’s Vapor Rub (to mask the smells, which are not only unpleasant but also sometimes dangerous as well), indelible markers to write on bandages, head lamps (to work hands-free), personal flashlights (with extra batteries), and cell phone chargers (for both wall and car) – because the availability of electricity is unpredictable. Also, the importance of pairs of inexpensive point-to-point portable radios – similar to those used by families in amusement parks to stay connected – becomes evident when cell phones are useless for any number of reasons.
What Leads to the Decision to Volunteer?
Most volunteers from the Mount Sinai Team who have been interviewed, and other volunteers who already have returned from Haiti, have said they wish they could have done more and, somewhat surprisingly, perhaps, wish they could have stayed longer. The feeling that they helped in some small way is something they said would stay with them for a long time to come, and might well motivate them to volunteer again, if and when needed.
The NGOs for medical volunteers – e.g., Partners in Health, International Medical Corps, Doctors Without Borders, and others – do a superb job. If healthcare workers want to deploy and to help in situations such as what happened (and is still happening) in Haiti or other distressed areas of the world, an association with such organizations can help provide them the support and protection they definitely will need. To self-deploy without affiliating with an NGO, though, as was seen, will likely result in personal frustration from not being able to help – and for that reason alone substantiates the need of an individual, as well as an organization, to participate only as a member of a strong and meticulously detailed pre-planned mission.
Theodore (Ted) Tully, AEMT-P, is President of STAT Healthcare, an Emergency Management consulting group. He previously served as Administrative Director for Emergency Preparedness at the Mount Sinai Medical Center in New York City, as Vice President for Emergency Services at the Westchester Medical Center (WMC), as Westchester County EMS (emergency medical services) Coordinator, and as a police paramedic/detective in Greenburgh, N.Y. He also helped create the WMC Center for Emergency Services, which is responsible for coordinating the emergency plans of 32 hospitals in the lower part of New York State.