ARTICLE IN BRIEF
Several military neurologists report on conditions and challenges in treating victims of the Jan. 12 earthquake in Haiti.
Lt. Commander Mill Etienne, MD, MPH, fled the bloody regime of Jean-Claude “Baby Doc” Duvalier in 1981 with his family at the age of five, but when he heard about the Jan. 12 earthquake in his homeland he knew almost instantly that as the only neurologist in the Navy who speaks Creole, his next mission would be in Haiti. Hours later, he went into his Bethesda Naval Hospital office, where he had been working since August, to put his work in order and volunteer.
The director of the EEG Laboratory at the National Naval Medical Center, who had last visited Haiti in 2004, still had many close family and friends living in Haiti. He later learned that one of his cousins had been buried in the rubble of the Hotel Montana in the Haitian capital, but was brought out alive after two days. Many family friends were not found.
Clydette L. Powell, MD, MPH, had first started traveling to Haiti to work with the Haitian Ministry of Health in their national tuberculosis program in 2001 as a medical officer at the Bureau for Global Health, United States Agency for International Development (USAID). As a child neurologist trained at Children's Hospital in Pittsburgh, with a background in epilepsy research and extensive experience in public health, she was welcomed by the commanding officer of the US Naval Ship Comfort.
Drs. Etienne and Powell met when the ship set sail from Baltimore on Jan. 16 along with 1,100 other medical personnel and support staff. They began seeing patients who were dropped off by helicopter even before the USNS Comfort arrived in Haiti four days later. The first to board were the sickest — neurosurgical patients with traumatic brain and spinal cord injuries and others with seizures and peripheral nerve injuries due to compression. The casualty receiving area had filled its 50 bays and was operating at maximum capacity from day one. Those patients were stabilized and either sent to one of eight operating rooms, or the ICUs and wards of the 1,000-bed ship.
Dr. Powell recalled seeing a woman in 29 weeks gestation with a pelvic crush injury, one of several who underwent C-sections on board. The premie had the usual medical issues, but because she was cared for by a full team of neonatal nurses and doctors, she received surfactant immediately in the delivery room, and after a short period of intubation, did very well. Another woman on board who had delivered a baby at 35 weeks gestation in Port-au-Prince on Jan. 11 had lost her husband and was left without shelter when their house was destroyed in the quake. By the time of their arrival it was too late; the dehydrated infant had developed sepsis and soon died.
“It was a tragedy,” Dr. Powell said. “Here were two babies born two days apart and the more premature child survived.”
A TYPICAL DAY
The day began at about 5:30 AM and typically ended after midnight for Drs. Powell and Etienne. They frequently missed many meals because there were so many patients to see, and as the only two neurologists on board, they were often paged after they retired. Dr. Etienne, who had trained at the Columbia Neurological Institute in New York and had stayed there to do epilepsy and neuroepidemiology fellowships, also treated many pediatric patients. Ten days after the earthquake he saw a 10-year-old boy who had developed abnormal movements of the head, tongue, arms, and legs consistent with choreoathetosis. “The child was no longer able to speak, button his clothes, or walk,” he said. On exam, Dr. Etienne heard a cardiac murmur, and the child's echocardiogram confirmed the presence of moderate mitral regurgitation. The child was diagnosed with probable rheumatic heart disease presenting as Sydenham's chorea, and treated with penicillin and valproate. By day two he had improved significantly and was able to walk with assistance; the ASO titer which had been sent to the US came back positive (over 700) a week following discharge.
The neurologists also helped care for an 11-month old boy with severe hydrocephalus. The boy's mother had told Dr. Etienne that long before the quake Haitian doctors had examined him and told her nothing could be done.
“Some of the problems we treat are not related to the earthquake, but the Comfort is the only hospital with advanced medical capabilities in Haiti at this time,” Dr. Etienne explained, adding that it was quite difficult for the homeless mother to carry a dysfunctional baby with a head circumference of 72 cm and growing. A neurosurgeon aboard the USNS Comfort argued that placement of a ventriculoperitoneal (VP) shunt had been done successfully in other underdeveloped nations and that it would offer the boy a better quality of life. After the surgery, a post-operative CT looked good and doctors on the ship arranged for physical therapy and began searching for a Haitian neurosurgeon that could follow the child. “Before the VP shunt, Natanel's mother had never seen him smile,” Dr. Etienne said.
A comatose seven-year-old girl who had suffered severe head trauma and deteriorating mental status was flown from a local hospital by helicopter to the USNS Comfort where Dr. Etienne was able to confirm on CT the presence of cerebral edema along with extensive fractures of the skull base.
Onboard the craft was fellow neurologist, Anthony G. Alessi, MD and their acquaintance spawned an active collaboration, still ongoing, with St. Damien, the nation's only free pediatric hospital, and its annexed orphanage, St. Germaine, located in the outskirts of Port-au-Prince.
They later met Air Force Major Brian M. Faux, MD, chief of child neurology at San Antonio Military Medical Center, who had trained in pediatric neurology at Stanford. Dr. Faux had arrived in Haiti on Jan. 23 and was seeing patients in a number of settings—including the local Air Force hospital (comprised of seven joined Alaska shelter-type tents), the joint task force flight line where he did aero-evacuations, and occasionally on board the USNS Comfort and St. Damien, where he worked alongside the other neurologists.
“I was amazed by the multitude and variety of neurological disease we saw,” said Dr. Faux, who was pleased to have been able to access the resources aboard the USNS Comfort, including the CT scanner with the ability to do 3D reconstructions. By comparison, the 20-bed land based Air Force hospital only had one operating room and could perform only plain films and basic labs.
Dr. Faux is now compiling a review of cases with Drs. Powell and Etienne. “They include meningitis, encephalitis, brachial and lumbar plexus trauma, all manner of intracranial trauma and hemorrhage, epilepsy (neurocysticerosis, congenital, febrile, neonatal, subclinical status), dementias, congenital anomalies such as untreated hydrocephalus, genetic conditions (Down, xeroderma pigmentosa, neurofibromatosis, microcephaly), tumors (optic nerve glioma), and psychiatric disorders (catatonia, malingering, conversion reactions, acute stress reactions), among others,” he said.
“We had one unfortunate 15-year-old boy who had survived the earthquake largely unscathed except for a right fifth digit distal phalange amputation sustained when a wall fell on it,” Dr. Faux said. The patient went without care for about two weeks, then developed tetanus involving opistothonus, trismus, sympathetic overdrive, and ultimately respiratory failure requiring intubation.
“Even the slightest stimulation would cause him to have bouts of stiffening, which required massive amounts of sedation pharmacologically to calm him,” he recalled. One of the first patients to be aero-evacuated to the United States, he was first thought to have seizures although there was no loss of consciousness with the generalized movements. “He was our first of six tetanus patients,” Dr. Faux noted, adding that the immunization rate for tetanus (and most vaccines) was at baseline 50 percent at the time of the earthquake, making this a major public health priority.
BONDING WITH COLLEAGUES
“There's an immediate bond when you meet other neurologists,” said Dr. Powell, who noted during her month-long stay that in spite of their varied alliances, they were free to work closely together wherever they were most needed, both on and off the ship. “On our first visit to St. Germaine the staff apologized that they had no medical records,” Dr. Powell said, adding, “but they seemed to know the cases well and were managing them appropriately.”
When they returned to the Comfort, the three neurologists created a simple electronic health template for the children they had seen at St. Germaine, which included a developmental history, current developmental functioning, key medical problems, a medication list, and a photograph.
“We went back for multiple visits in order to see all the children because many of them were quite complicated and had a wide range of neurologic problems including static encephalopathy, untreated epilepsy, or pharmacoresistant epilepsy,” said Dr. Etienne. “The medical record helped tremendously because now it's easier to keep track of the children; it will be especially useful in the next couple of months because they'll have to be moved from this orphanage and may end up at other hospitals,” he explained. He also spent a lot of time at the US Air Force hospital in Terminal Varreux, and recently went to the Partners in Health's flagship hospital in Canje where Chelsea Clinton was seeing patients with the medical group.
“Most pressing for neurologists are the chronic conditions that were left behind with physician evacuations and the overall devastated condition in Haiti,” said Dr. Faux. “Children with epilepsy are not being treated prophylactically with anti-seizure medications, only symptomatically with either benzodiazepines or phenobarbital, because the pipeline of medications into the country has been broken,” he explained. The international League Against Epilepsy has a Port-au-Prince chapter that had a regular clinic prior to the earthquake, but has now witnessed a tenfold increase in its demand.
“To me, getting anti-seizure medications to Haiti for a long term, sustained basis is the most pressing issue,” said Dr. Faux, who returned on Feb. 18. He and Dr. Powell are currently seeking help from the Epilepsy Foundation of America to see if much-needed anti-epileptic drugs can be sent over since so many pharmacies are in rubble.
Dr. Etienne, who remains in Haiti, pleaded: “We need more neurologists, physiatrists, and mental health professionals to come to Haiti and help out. Any neurologist who can volunteer time to come down to the country, would be very much appreciated,” he said, adding that those who are unable to come out can try to identify a hospital and form a partnership to help them through telemedicine. “Many of the questions about patients that I saw in the community hospitals for chronic issues could have easily been answered via e-mail,” he said.•
Neurology Today has published a series of articles abut neurology's response to the Jan. 12 earthquake. For an archive of past stories, go to neurotodayonline.com, search “Haiti.”