David Feldman's blog

Jan 30 08:23

My Perspective


NYU/HJD Haiti Mission
January 22 through January 29, 2010
Ken Mroczek and I joined the NYU/HJD mission to Haiti as the orthopedic contingent. We joined with Partners in Health (a non-profit nongovernmental organization that has a long and important history in Haiti). There were seven of us in all with different specialties and expertise. We all had different expectations and concerns and with three in the group being Hatian-American we had varied knowledge of the Hatian people, language and culture.
On the plane ride over we discussed how we would do whatever it took to help in some small way. As a surgeon, I had been very impatient in the week leading up to our departure because I knew that every day that passed my input and ability to change a patient’s outcome would diminish. We arrived in the early evening to the smell of a smoldering city and an airport and country that was in near total chaos.
The week mission is over now. I am home in the comfort of hot running water, warm meals and a comfortable bed.   I would like to share what I learned as a person, physician, division chief, and administrator. There are many facets to this learning experience and several had little to do with the crisis itself.
To describe the setting, we were placed in the largest hospital in Haiti which is the general hospital in Port-au-Prince. Even before the earthquake this was a hospital with very few resources and a barely functioning operating room. Port au Prince at this times looks like the pictures I have seen of Dresden during World War II. There are very few buildings still standing, with rubble and exposed wires everywhere. The dust, heat and smell of decaying bodies permeate the city. Tent cities are scattered throughout the parks with the bustle and traffice of a chaotic city continuing. The Hatian people are a proud people who are quite fastidious concerning their personal appearance. Even in this tragedy, nearly to a person, they were clean and well dressed with the white of their shirts whiter than white. Considering it is a city now with no running water or electricity, this is quite a fete. While I am sure there is crime, like any big city, we never felt threatened in any way and on our last day four of us walked through the city without any need for an armed guard.
We were sleeping in a courtyard of what appeared to be a school at the end of a runway at the airport. We had running water by day three but I never got used to the sound of C17 cargo plane one hundred feet above my head at 2 AM. Our camp was between 20 minutes to an hour away form the hospital depending on how much coffee the driver had that morning or afternoon.
I will start with what I saw and learned as a surgeon in order to help other orthopedic surgeons who wish to do similar work. First one must place his or her own ego aside in doing a mission like this. It is not about doing the “greatest” case or being recognized for saving a limb or a life. There are no surgical heroes in these situations and this is neither a movie nor a CNN special. We are not discovering the cure for cancer; we are simply contributing a service where we are needed.    If at home you have residents to make rounds and change dressings that does not exist here. No matter how senior, we all changed dressings (Mary Ann reminded us of this until it became second nature), looked at surgical wounds, placed IVs and transported patients.
Second, one must know their skill set. Ken and I witnessed surgeons and non-surgeons performing procedures that was not at all what they were trained to do. This is not okay. If there are others to help you, then use that help and assist them. Fritz and Pat did what they did best, cared for sick adults and children respectively. We joined our surgical team with another Partners in Health group from Boston Children’s, Bringham and Women’s and MGH that included trauma/vascular surgeons and Plastics/Ortho surgeons . This relationship, as I will discuss later, allowed us to accomplish more than we ever expected. There is no credentialing committee in crises and one must know their own skills and defer to others to achieve the best result. Because of my experience with limb deformity, I placed a large number of external fixators and Ken assisted on nearly every one. For a few cases I acted as the scrub nurse and/or circulating nurse when we were short nurses. We helped each other often, in decision-making and in the surgery itself.    First and foremost Ken and I always maintained the question that is what we are doing truly helping this patient in this situation? Therefore if you are reading this long winded account and you have experience with and comfotable treating orthopedic trauma, then you can certainly be of immediate help in these situations.  Residents should be accompanied by attendings and not attempt to do this alone.  If you do not feel comfortable with trauma, there is still help that you can render.
We had few resources and a suboptimal operating room with suboptimal sterility (especially when we first arrived). We needed to keep things simple and safe. Although certainly capable of doing so, we did not do any open reductions of fractures or intramedullary rods and made sure those cases such as a femoral shaft fracture in an adult went to an appropriate outlying facility such as the USS Comfort, a US Navy ship that had fully functioning ORs. We were also sensitive to the people of Haiti and although a number of limbs we treated may eventually come to amputation, the team salvaged all limbs and performed no amputations. The trauma victims had become very concerned that all the foreign doctors were going to do was cut off their limbs and before every surgery we re-assured the patients and their loved-ones that this was not the case. I discussed the surgery with the patient and a translator each time. While there is no informed consent forms, these are people who need to be treated with respect and caring, even in this dire situation.
The next lesson I learned is how to be part of a team and what skills are needed when entering this situation. When we arrived there was no fuctioning operating room and hundreds to thousands of people requiring surgery. No functioning x-ray for a few days. No xray in the OR at all.   Patients were for the most part in multi-personed tents or outside under trees or make-shift tents. Most buildings were not habitable. There were multiple groups from all over the world setting up their own little mini-camps within the hospital and performing procedures with little resources. Within one day, with the help of nurses, techs, surgeons and anesthesiologists we had a primitive but functioning OR- suite of 4 ORs. By the second day we had joined forces with the Mount Sinai group who had come with many para-professionals including a supply chain expert (Mike) and our OR had a sterility process (even without an autoclave). With only few exceptions we worked together to make this work. We scoured the patient tents and a place we called the forest, where patients were scattered under trees in the middle of the facility. There was one physician trying to help 50 patients. We found patients with untreated open fractures, untreated pelvic and femur fractures and open and/or infected stumps. We prioritized the need and actually created with a nurse (Stella) and an anesthesilogist an OR schedule. We often made rounds with an anesthesiologist in order to make dressing changes more humane. There was a time when we had 20 patients in a tent all on Ketmaine. It was like a 1960s LSD party. We had one tent which was run by critical care and ICU nurses and we made that our post op critical care unit. These Dartmouth nurses were talented and incredibly dedicated to these patients. We could not have done it without them. As the days went by we actually created a map of the facility and with the help of BB, an emergency room doc from California, we created a pre-op unit which patients either were treated by us the French, the Swiss, the Norwegians or were transferred to other facilities. With the help of International Medical Corps (IMC) led by Paul, Bob and Anil, we were able to identify, which patients would go where and with Colonel Malsby of the US army, we became as efficient as possible in getting the patients the appropriate care they needed as quickly as possible.
How do you deal with so many small groups who were running their own show? This is a difficult question and is unique to crises. Unfortunately, several groups were more interested in the media and the cameras then in the optimal care of the patient. The media is looking for the miracle story and/or the crisis problems that care takers are not solving. For the most part these do not exist and it is never as good or as bad as some of the media portrayed. We solved this problem by constantly engaging the international groups. We used our pre-operative area to feed the French contingency surgical patients. We shared resources of equipment etc with whoever needed. I would start my day at the Swiss Pediatric tents talking to Axel, their surgeon, and seeing how I could help. Gradually barriers were broken and all was collegial if not actually friendly.  Amazing that there can be turf wars when there is so little at stake. Left to nature, we would have had the Lord of the Flies. The goal was the quality of patient-care, not us.  There most definitley needs to be a more coordinated multinational response team.
Let me say a few words about the us, i.e the surgeons. Ken Mroczek, chief of foot and ankle surgery at NYU/HJD, Johnathan Gates, Medical Director of trauma surgery at Bringham and Women’s Hospital, Mary Ann Hopkins, General Surgeon, NYU medical Center,   John Meara, Chief of Plastic Surgery at Boston Children’s hospital, Gary Rogers, Plastic Surgeon, Orthopedic Surgeon, Hand Surgeon, JD, MBA, MPH at Boston Children’s Hospital, Joaquim Havens. Ex-Navy seal and Chief Resident of Surgery at Bringham and Women’s Hospital, Bill Perenteau, Chief Resident of Surgery at Bringham and Women’s Hospital and myself, David Feldman, Chief of Pediatric Orthopedic Surgery at New York University and Hospital for Joint Diseases. Those are all pretty impressive credentials. There was not a moment of discord between any of us in the group. Everyone did jobs from the most menial tasks to the most complex surgery without a single word of complaint.   We were colleagues and we became friends. We utilized each other’s surgical skills to make the patient outcome the best it could be. One case in particular that stands out for me is a five year old girl with an infected complete degloving injury of the upper extremity with a multiply fractured and dislocated elbow. The child had been treated in another part of Haiti and was sent in with a seemingly unsolvable problem. Gary Rogers and I worked together as if we had been working together for years and jointly we were able to fix the elbow and then transport the child to the Comfort for completion of her care.
 We worked hand in hand with the nurses and anesthesiologists (who were the best and most dedicated I have ever worked with) to make an operating room that was real and functioning. On our second to last day we performed 26 operations closing wounds, skin grafting and completing what we had started and on our last day we were able to transition this OR to the Hatian doctors. This is the part I am most proud of.
I have learned that the first response team MUST include trauma, plastic and orthopedic surgeons with the emergency doctors. These surgeons must be willing to be the first line in order for example to splint extremities correctly and prevent unnecessary amputations and amputations performed incorrectly. As you exit the first days of a crisis you need an internist and pediatrician to take care of sick patients, you need ER doctors to triage and treat, you need talented anesthesiologists, trauma surgeons, plastic surgeons and orthopedic surgeons. Within a week, the role of the trauma and general surgeon diminishes and you need more orthopedic and plastic surgeons. As a team who wishes to be self-sufficient, you need OR techs and experts in setting up an operating room. You need talented indefatigable OR and ICU nurses. You also need to incorporate the local people to help you in all ways from physicians to transports.
I will end this review with a word about the American Armed Forces. Unfortunately, previously I  had little to no experience interacting with our armed forces. In Haiti the army maintained order and we worked closely with them. Each soldier I came in contact with was expertly trained, intelligent, disciplined, kind, helpful and dedicated. The Medics operated with us and at times they too performed the most menial tasks always with smiles on their faces. One unfortunate story was of a local doctor who delivered a full term still born child in the Swiss OR. The doctor, for unknown reasons, discarded the dead newborn child on the floor. The US medic (Patrick) asked the doctor to pick up the child. The doctor stated, “it was not his job”.  The soldier instead of creating an incident, picked up the child and wrapped the body and treated it with the respect it deserved. One story and there are many others. Without the tireless work of the US army, Haiti could not have pulled through the first weeks of this crisis. We often forget, due to media reports, how incredible these true patriots are and my attitude and love of these men has been changed forever and I will support and help them in every way possible.
The cameras will soon leave Haiti except for an occasional follow up human interest or “how are they doing now?’ story. I will return to Haiti in the next six weeks and partner with an effective NGO to help follow the numerous patients treated with external fixators etc. If you wish to help don’t do it alone- lone rangers don’t function well in these settings. Join a mission or an NGO and find where you can be most useful with the skills that you have. If you wish to give money, then give it to an organization that you know exactly what they are doing. I hope I have become a better person from this past week but I will leave that for others to judge. I will sign off by thanking PIH for creating this group, Natasha for dealing with all the nonsense of accommodations and transport, Fritz Francois for his impassioned care of patients and running this mission, Pat Poitevien for sharing her language, cultural and medical expertise and NYU for allowing and enabling us to do this mission. I also thank with all my heart: Stella, Jay, Prisca, Trish, Liz, Lucy, Pam, Joanna - the nurses. As well the nurses of Mount Sinai in NYC who were wonderful and I am grateful to them. I also thank Craig, Emily, Monica, Daina, and Dave the anesthesiologists and all others I have forgotten who made this an unforgettable and effective journey. To Ken, Gary, John, Mary Ann, John, Bill and Joaquim -the surgeons, you truly were the best and most humane group of now true colleagues and friends I ever could have hoped to work with.
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