To the Editor:
On January 12, 2010, the Island of Haiti experienced a 7.3-magnitude earthquake centered 16 miles from Port-au-Prince, the capital of Haiti. The Haitian government estimated that 200,000 people were killed and as many as 3000,000 people were affected by the earthquake.1
In response, President Obama pledged aid and support for one of the largest international relief efforts in history. The US Agency for International Development was placed in charge of earthquake response and requested United States Public Health Service to activate the National Disaster Medical System (NDMS).
NDMS is a federally coordinated system for national medical response. The NDMS was designed as part of an integrated national response, temporarily augmenting state and local authorities in dealing with the medical impacts of major peacetime disasters. It consists of state-based teams of volunteers who train and respond to local and national disasters. The most common team is the Disaster Medical Assistance Team (DMAT), which can provide urgent medical care on short notice and can operate small clinics and hospitals. DMATs are fully self-supporting with physicians, nurses, administrators, logistics, and pharmacists. The author is a member of MO-1 DMAT and on January 22, 2010, was activated for deployment to Haiti with his team. MO-1 DMAT is a level 1 team, fully capable of independent operations for 72 hours and longer with resupply (level 2 teams could be deployed to replace a level 1 team but were not fully capable; level 3 teams are for local use only and do not deploy; and level 4 teams are notional only). The MO-1 DMAT team consisted of 36 individuals including 3 physicians (2 family practitioners, 1 occupational medicine physician), 2 nurse practitioners, 3 pharmacists, 12 nurses, a psychologist/chaplain as well as paramedics, administrators, and logicians (SDC 1, http://links.lww.com/JOM/A30).
In addition, an International Medical Surgical Response Team (IMSURT) had been deployed to Haiti. The IMSURT is a surgical team capable of establishing a field surgical unit. A Disaster Mortuary Operational Response Team was later deployed to the Toussaint L ‘Overture International Airport at Port-au-Prince to assist in identification of American casualties.
NDMS had never performed an international deployment before although there had been frequent activations and deployments of DMATs and IMSURTs (which did have one international deployment to Iran in 2003) within the United States for such events as Hurricane Katrina or state emergencies such as ice storms and floods.
The role of the Occupational Health and Preventive Medicine Specialist was understood at the national level, and Public Health Service Managers had taken many of the potential health threats into account with regard to deployment to Haiti. However, the role of the occupational health provider at the level of the DMAT has not been defined and has been a function of the individual teams. The experience of the Haiti Disaster Relief Deployment is a case worthy of evaluation.
After activation on January 21, 2010, the team required assessment of disease threats and fitness for duty. MO-1 DMAT was initially staged to Atlanta, Georgia, where NDMS provided vaccinations and training as well as respirator fitness. This training was performed by a DMAT specifically activated to operate the predeployment facility and supervised by US Public Health Service officers. Potential for infectious disease from malaria was briefed to the team, and antimalarial medications were provided. Some team members had obtained their own medications before deployment, including Malarone, doxycycline, and mefloquine. Those who had not obtained medications before deployment were provided Malarone in sufficient dose to cover the anticipated 14-day deployment and 7-day postdeployment therapy. Additional training was provided for heat stress, hydration, and buddy care. These would prove to be essential during the actual deployment.
The medical team commander and the occupational medicine physician also performed Fitness For Duty Evaluations. Each team was responsible for its own members, so the assessment was done by any available health care provider. Because MO-1 DMAT had an Occupational Medicine physician, he assumed the responsibility. These included evaluating each of the 36 team members for current reported health status and medications. Four individuals were further individually evaluated because of potential medical conditions which included three individuals with a calculated BMI >35%. (Deployment had been previously prohibited for individuals with a BMI ≥40%, and this was changed for this deployment.) One individual was also an insulin-dependent type 2 diabetic. After the occupational medicine physician performed individual assessment and evaluations and reviewed the team member capabilities, three were cleared. The fourth individual remained questionable on a physical basis, and a Functional Capacity Examination was performed. It was projected that the heaviest physical activity during deployment would be a requirement to carry all personal gear a distance of one-quarter mile, and this was simulated at the staging location by having the individual carry her full load ∼400 yards and then climb several flights of stairs. She was able to accomplish this without incident and was cleared for deployment.
General operational information was briefed to the team before deployment. However, all information was cautionary, and the actual deployment assignments were not made until shortly before the teams left. The teams were not informed of their assignments until they arrived in Haiti. Off shore, the USNS Comfort, a Navy Hospital ship, was operating at partial capacity with 350 beds available. Department of Defense airlift for in-country and medical evacuation to NDMS supporting hospitals was also operational. As of February 12, 2010, ∼25,052 people have been evacuated from Haiti to the United States. Of these, ∼23,630 arrived in Florida. Repatriation services—including medical attention—have been provided to ∼7438 American citizens and were coordinated by the state emergency repatriation teams. Of these, ∼6930 were in Florida.
The initial duties assigned the MO-1 DMAT team were projected to have been operating a clinic at the United States Embassy at Port-au-Prince as well as a clinic on the airfield and Fond Parisien and providing medical support for the recovery team at Hotel Montana. These are fairly small operations typically conducted under the aegis of one or two physicians and do not anticipate in-patient care, only temporary holding of the patients. In route, however, assignments were changed. Since the MO-1 was a level 1 team, the assignment was changed, and the MO-1 DMAT was assigned to GHESKIO Field Hospital,2 in conjunction with IMSURT-West for additional manpower and expanded capability for the surgical field hospital. This was an assignment that DMAT had not previously filled, and the duties particularly for the medical members of the team were considerably different. This assignment was made at the Port-au-Prince airport while on the tarmac and only limited information was available.
Resupply and logistical capabilities for the IMSURT and the DMATs were significantly different and so at all levels, flexibility was essential. This was successfully carried out and considerably improved the IMSURT operation. Most resupply of GHESKIO Field Hospital was through use of DMAT caches flown in by US Air National Guard aircraft and additional supplies provided from the Israeli Army Hospital and various NGOs.
The three physicians found that instead of operating strike teams and an outpatient clinic, they were essentially expected to fulfill the role of inpatient hospitalists. In fact, the IMSURT which consisted of 12 surgeons and 2 anesthesiologists had no nonsurgical physicians assigned. The Medical Director for DMAT-1 coordinated roles and the three physicians worked as hospitalists as well as conducting triage for an outpatient clinic (SDC 2, http://links.lww.com/JOM/A31). The Public Health and Occupational Medicine role was assumed without being assigned to the occupational medicine physician (SDC 3, http://links.lww.com/JOM/A32).
The first question on arriving at the GHESKIO Field Hospital was to evaluate occupational hazards, including needle stick protocols and sick call. It was discovered that there was no needle stick protocol and antiviral drugs had not been specifically provided. In short order, a needle stick protocol was established even though the IMSURT had been in position for ∼8 days. This was extremely timely as within the first 6 hours, there were two needle sticks. Both of the donors were tested by the Occupational Medicine physician using rapid serology tests for HIV 1/2 and found to be negative. This role continued on during the 10-day deployment at GHESIKO Field Hospital with a total of six blood and body fluid exposures, one donor of which was demonstrated to have come from an HIV positive individual. The recipient was initiated on the standard CDC antiviral protocol.
In addition, potential exposures existed for the deployed members of the IMSURT and DMAT team, which included two meningitis cases and resulted in 27 team members being exposed and placed on prophylactic antibiotics without incident. Rifampin was not in the pharmacy, and alternative medications were prescribed. Active tuberculosis patients were also seen and admitted into an improvised isolation ward. Directly observed antituberculosis medications were obtained from the Haitian GHESKIO Clinic, which was still fully functional (founded in 1983 by Dr Pape, Groupe Haitien d'Etude du Sarcome de Kaposi et des Infections Opportunistes or Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections). All team members had been trained in the use of N95 respirators and their use was strictly enforced albeit after the first meningitis exposure case.
Sick call was also provided for care of the IMSURT and DMAT members as well as the a platoon of the 82nd Airborne Division, which was billeted at GHESKIO Field Hospital and assigned for site security. The soldiers of the 82nd Airborne provided superb support both in security and volunteering for additional duties such as a corpsmen assisting with medical care and training. Other soldiers volunteered to help provide prolonged physical effort such as hand bagging certain patients. The entire IMSURT/DMAT cadre consisted of only 86 individuals, and manpower was extremely limited.
The greatest threat to the health and safety and conduct of the GHESKIO Field Hospital mission was illness among the members of the staff. We experienced 14 cases of mild gastroenteritis. However, in the extreme heat of the environment where most days were more than 95° Fahrenheit and high humidity, and nighttime temperatures dropped as low as 80° Fahrenheit, mild dehydration by gastroenteritis could prove debilitating. On top of this, the pace particularly within the surgical ICU was frantic, and IMSURT team members often did not take care to follow the same buddy care and hydration schedule that the DMAT members were following. Added to this was the thermal load inside surgical tents, which often exceeded 105° Fahrenheit. As a result, 13 of the 14 gastroenteritis cases requiring intravenous rehydration were from the IMSURT team. All individuals recovered rapidly and were returned to duty within 24 hours. Command took considerable leniency in returning these individuals to work and permitted a much more relaxed schedule and return as tolerated.
Site sanitation was of considerable concern. The original location within GHESKIO was that of a small school attached to the GHESKIO clinic. The Union School yard consisted of a small quadrangle of buildings ∼20 yards × 80 yards with six tents pitched within the quadrangle. The water supply had been disrupted and sanitation cut off. The initial setup of the facility was suboptimal. This resulted in three diesel generators being placed directly beside a tent used for sleeping and two other diesel generators within the compound, all five running continuously. Despite the extremely loud environment, because of exertions of the team members, sleep was not disrupted. Water supply was limited and bottled water was the only source for drinking. Water was made available for hand washing but was nonpotable.
For the first 6 days of the deployment, showers were not available and after that became available only on a very limited basis. Sanitation was also limited and “gray” water as waste from the hand washing facilities was recovered and used to supply commode reservoirs to enable flushing of the toilets. Hand washing was emphasized with great authority, using both soap and water as well as waterless sanitizers. Two clinical cases of Clostridium difficile enteritis were identified in patients and hand washing was again emphasized. Trash, both normal and medical trash, was burned in a small area adjacent to the GHESKIO building. However, this was a less than optimal location, and the trash burning site was upwind of the facility about half of the day. Only late in the deployment was trash collection reinitiated and the burning stopped.
Additional sanitation concerns grew from the Haitian “tent city,” which was located on the soccer field adjacent to Union School. Approximately 3000 Haitians were encamped here in makeshift structures. There were no sanitary facilities available and waste became a major issue. As a result, the Occupational Medicine Physician accompanied by a US Army soldier trained Haitian health care providers from GHESKIO as to field sanitation techniques, including slit trenches, burnout latrines, and field urinals. The presence of the US Army cannot be understated. The Army's experience with a similar encampment of 8000 soldiers in the desert of Iraq for a period of 6 months without health issues due to waste disposal impressed the Haitians significantly and greatly assisted their motivation. The Haitians themselves were responsible for establishing the sanitary facilities and their maintenance.
On the second day at the facility, the Occupational Medicine Physician who had been designated the Infectious Disease chief was asked to see a patient with a gangrenous foot. On his arrival in the tent/ward, he immediately identified active tetanus with trismus (lockjaw) and classic opisthotonus. The patient was a young adult Haitian male and he was immediately transferred to intensive care and tetanus antiserum (horse serum) was administered intramuscularly. Anesthesia intubated the patient and surgery performed an amputation of the foot with additional antitoxin provided. The patient did survive. Subsequently, two additional cases of tetanus, including a fatal neonatal case, occurred at GHESKIO Field Hospital and two other cases of tetanus, which did not survive were identified by other DMAT units in Port-au-Prince. More than 500 doses of tetanus diphtheria vaccine were available in the DMAT cache, and the Occupational Medicine Physician directed that these should be administered to all admissions and patients seen in the triage. By the third day, more than 500 doses had been administered and another 500 doses were delivered to the clinic when the Israeli Field Hospital was closed and its supplies turned over to GHESKIO Field Hospital.
Additional recommendations and training for the staff emphasized hydration and electrolyte replacement. The logistics team was able to obtain several electrolyte supplements, and the main meals that consisted of a single Meals Ready to Eat (MRE) per person per day were also noted to contain as much as 55 mg of potassium chloride in the electrolytes supplement. The MRE consumed by the IMSURT/DMAT members was adequate although most individuals lost several pounds. This was because virtually every member of the teams took out some parts of their meal and provided it as food for the Haitian patients and families. Most Haitians in the hospital were actually fed by family members as is traditional in Haitian hospitals. There were some patients who did not have family members available, and in particular, some individuals were unable to eat solid food or infants. They were fed using food provided in the MRE, in particular, the strawberry milkshake substituted for infant formula.
Additional efforts to reduce heat stress such as obtaining a second layer for the tents were rejected by management and indeed management of the IMSURT was not fully familiar with the role of Occupational and Preventive Medicine except in a limited form regarding tropical diseases. Advice was in general unwelcome.
On February 4, 2010, both teams were replaced at GHESKIO Field Hospital by IMSURT-South. The three nonsurgical physicians were replaced by a single internist and the role of the hospital was reduced to surgical care only. The triage and outpatient care was handed over to an NGO.
On arrival at the Port-au-Prince airport, three ailing members of the Disaster Mortuary Operational Response team were also onloaded and evacuated back to the United States. The Occupational Physician, being a former US Air Force flight surgeon, was familiar with aeromedical evacuation and assumed in-flight care, ably assisted by a nurse-practitioner. The DMAT carries a “comfort kit” of medications specifically designed to provide for the needs of team members during transit and this was used.
The teams were flown to Dulles Airport in Washington, DC, and debriefed that evening. Public Health Service provided briefings, including tuberculosis testing follow-up as well as a needle stick testing follow-up for HIV and hepatitis B and C. Additional representatives from Substance Abuse and Mental Health Services Administration provided a briefing and information regarding stress for disaster response workers.
The Occupational Medicine physician continues to provide update information and consultation to team members by e-mail.
Overall, the occupational medicine role was essential in the conduct and completion of the NDMS mission. The Public Health Service had anticipated much of the preventive medicine role, and pre- and postdeployment medical concerns were well addressed. The operational role on scene, however, was not fully appreciated by the management of IMSURT, which was not familiar with the DMAT role and provided only limited support. The DMAT teams, however, fully understood the issues, and in the opinion of the author, if the DMAT had been placed in operational control with the IMSURT as an embedded surgical hospital, many of the occupational and logistical problems could have been solved. Without preventive medicine and occupational health, the success of any disaster response team is in jeopardy.
Ultimately, the performance of each and every team member was outstanding. We felt that the mission was worthwhile. In the back of everyone's mind, it was a rehearsal for the “Big One.”
Allen Parmet, MD, MPH
St. Lukes Hospital
Kansas City, MO