On Tuesday, January 12, 2010 at 16:53 local time, a magnitude 7.0 Mw earthquake struck Haiti. Early estimates of those killed immediately exceeded 100,000 persons and is now determined to be >200,000; the actual number of dead may never be known.1 According to the most recent records from 2008, the population of Haiti before the earthquake totaled 9.8 million persons, making this earthquake one of the most lethal earthquakes on record.2 Injured patients lay buried in rubble, exposed on the ground, or “protected” in make-shift tents. The number of injured quickly overwhelmed available health care resources, especially given that many health care facilities located in the earthquake zone were severely damaged or destroyed, and many of the health care workers were killed or injured, or had family members who were killed or injured.
The global humanitarian attempt at response was swift, but poor infrastructure and emergency preparedness limited many efforts.3 The Haitian government was severely affected by the earthquake, with severe loss of life and destruction of many key government buildings. Electricity, water, and food were in short supply, and security was compromised. Transportation to and from the country was initially very limited, because access to the only airport was extremely restricted until the United States (US) Air Force assumed responsibility for security and air traffic control. Rapid, successful deployment of emergency medical care teams was accomplished by those organizations with experience in mass disaster casualty response, such as the military, government-sponsored groups, and disaster-management associations.4 Emergency medical care was also accomplished by health care organizations that had little experience in disaster management, but that had a strong presence providing routine health care in Haiti. Well-intentioned medical teams also responded in an effort to save lives, but were ill prepared for the conditions.5
Four days after the Haiti earthquake, the medical relief organization Partners in Health (PIH), a nonprofit, nongovernmental organization based in Boston, Massachusetts, contacted the Hospital of University of Pennsylvania (HUP) to request trauma and orthopedic surgeons, anesthesiologists, and emergency room personnel to provide medical support (personal communication, Dr. Jennifer Cohn, Director of Global Health Equities Residency at University of Pennsylvania, 2010). PIH initially communicated with Richard Shannon, MD, Chairman, University of Pennsylvania (Penn) Department of Medicine, who has worked with PIH in the past, and Naomi Rosenberg, a second-year Penn medical student who has also worked previously with PIH in Haiti. PIH has provided extensive health care services in Haiti for decades. Many of the PIH health care facilities are located outside of the earthquake zone, but close enough to Port-au-Prince to provide much needed health care services to individuals injured by the earthquake. Dr. Paul Farmer, the founder of PIH, with extensive ties to Haiti, was appointed to be the United Nations Deputy Special envoy to Haiti to help coordinate emergency health care services.
Because of the experience and the infrastructure offered by PIH, and their work with Homeland Security, the State Department, and the Clinton Foundation, Penn Medicine decided to work exclusively with PIH for any medical mission work within Haiti. PIH notified the University of Pennsylvania that the first medical team should be composed of no more than 9 members, and have the ability to provide trauma and orthopedic surgical services. This was due to expected limitations based on transportation, and the team was told to carry no more than 20 lb. per person of personal gear plus 900 lb. of medical supplies. The requested team composition consisted of 2 anesthesiologists or nurse anesthetists, 2 orthopedic surgeons, and nurses (postoperative/critical care). PIH request mobilization to Haiti within 48 to 72 hours, thus an urgent response by the HUP team was implemented. No specific information regarding in-country equipment, medications, case type or load, or hospital location was provided, thus the design of the preparation was more universal. Twenty-four hours before deployment, the team was informed that they would be working in a PIH hospital outside of Port-au-Prince in Cange, Haiti. Information to guide the response was abstracted from previous disaster response literature,6 – 19 news media, and late in the preparation period, from a US disaster team (Dartmouth Medical Center) already working in Port-au-Prince, Haiti, and through PIH from the medical team already deployed in Cange. Little of the published literature during our readiness preparation dealt specifically with suggested anesthetic supplies or equipment, thus further challenging us to develop a supply list that was appropriate for this mission. Seventy-two hours before mobilization, the aircraft for team transfer was changed and there were fewer weight restrictions. We describe the multidisciplinary process used at the University of Pennsylvania Health System (UPHS) to respond and prepare for this request, with a focus on anesthesiology readiness, up to the time of our medical team's departure to Haiti.
A real-time qualitative assessment and systematic review of actions and communications relevant to the Haiti earthquake by HUP Department of Anesthesiology and Critical Care, UPHS, and the University of Pennsylvania School of Medicine from January 12, 2010 to January 25, 2010 were performed. Information relevant to mission support by the Department of Anesthesiology and Critical Care was extracted. To provide a summary of communications and pre-deployment actions and lists generated through the decision-making process, the following items were reviewed: notes from faculty and staff meetings, notes from conference calls, electronic mail, and agendas and summaries of team meetings. Three key themes were identified for specific focus of this report based on the amount of time and attention given to these issues: staff selection, equipment procurement, and readiness for deployment.
A timeline for key activities that occurred after the Haiti earthquake is shown in Figure 1.
After the request for support from PIH, the chairman of the Penn School of Medicine Department of Anesthesiology and Critical Care contacted key faculty with adult trauma (MM), emergency preparedness (CWH), and global health (MM) expertise to ask for assistance in responding to this request. Anesthesiology residents were excluded from volunteering for this initial response because of the determination that senior anesthesiology faculty would provide greater flexibility. Several key criteria were developed to guide selection of anesthesiologists for inclusion on the team. Key criteria included prior or current military experience, physical fitness, competence in regional anesthesia techniques, organizational skills, and the ability to work as an integral team member. The criteria were developed in conjunction with the Chief of Trauma Surgery coordinating the Penn response (CWS), who was in communication with PIH and in contact with relief personnel in Haiti to best determine the type of practitioner needed and best suited to the mission. The team composition was changed to include 5 physicians: 2 anesthesiologists, 2 orthopedic surgeons, and 1 trauma and critical care surgeon. The nursing complement was altered to include 2 surgical critical care nurses, 1 operating room nurse, and an operating room technician. The anesthesiology team member profile was limited to senior clinicians with broad-based operating room, critical care, and pain management experience; previous military experience was also a criterion for selection because of the security-related concerns reported by news agencies from Haiti at the time, and the likely need to live and to practice in austere conditions. A request for volunteers was then distributed to the adult anesthesiology faculty (n = 84) asking for those who could potentially leave within 24 hours. Fourteen faculty members (17%) responded initially, all of whom volunteered to deploy to Haiti to support the relief effort. The 2 anesthesiologists selected for deployment (MA and TF) met all criteria.
Pre-deployment team members at HUP communicated with the Dartmouth Medical disaster response team on the ground in Haiti and with PIH to perform a needs assessment for desirable and necessary equipment. This was in continuous flux because the location of our team deployment was initially not known. Literature on recommended equipment and medications usually needed for emergency medical care in low-income nations, and after a disaster, was reviewed,6 – 19 although only a few dealt specifically with anesthetic needs. One of these articles reported on anesthesia planning for disaster response after the 2004 tsunami in Southeast Asia, although the care was provided on the US naval ship Mercy, which is a supertanker with full operating room and critical care capabilities.17 A second report listed “contents of medical-disaster-response backpack and equipment”13 with airway management equipment and some medications, but this kit is designed for rapid (<72 hours time to response) disaster teams. The article by Tobias et al.18 was the most complete guide. A preliminary equipment and medications list was then generated by our team. This list was reviewed and compared with both the World Health Organization (WHO) Essentials of Trauma Care and the WHO Global Initiative for Emergency and Essential Surgical Care (GIEESC) lists, and revised accordingly.a
The aircraft ultimately supplied to our team was a Gulf Stream IV jet, privately owned by an individual who donated its use and crew as a charitable contribution. Thus, each team member could take 40 lb. of personal gear, and 1200 lb. total of medication and general medical and surgical equipment was allowed. A 1200-lb. weight limit for all equipment to be transported (including medications, surgical and orthopedic instruments, and team member personal baggage) presented challenging restrictions, particularly with regard to IV fluids. Furthermore, although initially considered, neither oxygen cylinders nor concentrators were considered for the final equipment list because of the weight restrictions. The planning team had knowledge before deployment that functional autoclaves were available. The anesthesia-related final equipment and medication list that accompanied the team is shown in Tables 1 and 2. All items were donated by the UPHS.
Preparedness Training and Readiness Support
After determination that the UPHS and HUP would partner exclusively with PIH, UPHS decided that volunteers selected to participate on sponsored medical missions to Haiti would do so as part of their employment with UPHS. Therefore, UPHS staff would continue to receive salary and benefits while on the medical mission, and UPHS assumed financial responsibility for the costs of required immunizations and prescriptions related to the trip (see below).
In addition to contact with emergency medical relief teams who were already positioned in Haiti, we contacted the American Society of Anesthesiology Committee on Trauma and Emergency Preparedness (COTEP) to request distribution material, data collection tools, and relevant information. The COTEP had facilitated a request from the Assistant Secretary for Preparedness and Response at the US Department of Health and Human Services, who was seeking to partner with the American Association of Medical Colleges to identify specialty physicians willing to volunteer to deploy with Health and Human Services National Disaster Medical Assistance teams to Haiti. The WHO GIEESC project director in Geneva was also queried for available materials to prepare the team for their work, and to request a tool for onsite determination of adequacy of resources. The only available material was the WHO Situational Analysis Tool, designed for use in stable, functional low-income-nation facilities, and not appropriate for adaptation in a disaster/emergency response.
All members of the medical team were required to see the HUP Travel Medicine office and the Occupational Medicine Clinic at least 72 hours before scheduled departure. Both offices created flexible clinic hours to facilitate team members being seen. Centers for Disease Control recommendations for travel to Haiti were followed. Immunization, prophylaxis, and real-time treatment of diseases for in-country exposure that were provided for the team are shown in Table 3. In addition, staff members were counseled on protection from mosquitoes, oral intake to prevent both dehydration and infection, and sun protection.
To prepare the team for emotional, mental, and social stresses, daily team briefings and team-building sessions were held by the faculty member in charge of the deployment (CWS). This effort was challenging because of previously scheduled clinical responsibilities for each member of the medical team. The anesthesiologists were relieved of duties for several days before departure and departmental coworkers back-filled as necessary to promote these efforts.
Because of the rapidly changing situation in Haiti, PIH was not able to inform the team which specific PIH site they would be assigned to. As a result, the team made preparations based on available information relative to performing assigned duties in an austere environment and in Haiti in particular. Site-specific information was not available to the team until 24 hours before departure.
Preliminary Information on Deployment Team Response
The Penn 9-member team was flown to Port-au-Prince, Haiti on January 25, 2010, and drove to the village of Cange, Haiti the following day in a 4-wheel-drive vehicle. Cange is a small remote village in the Central Plateau of Haiti on the edge of Lake Péligre; it is the location of an American-funded hospital run by PIH featuring a 104-bed facility with 2 operating rooms. The Penn team performed 76 operations and approximately 40 anesthetic procedures outside of the operating room for dressing changes and casts (many bedside sedatives were administered IM). There were no major adverse events. A thorough description of the cases and experiences of the medical team is currently under review for publication.
Although only 11% of the people exposed to natural hazards live in developing countries, they account for >53% of global deaths due to natural disasters.7 Natural disasters killed 235,816 people in 2008, a death toll that was almost 4 times higher than the average annual total for 2000 to 2007. Cyclone Nargis left 138,366 people dead or missing in Myanmar, and the Sichuan earthquake in southwestern China killed 87,476 people; these 2 disasters accounted for the majority of deaths.7 The Haiti earthquake surpasses all recent disasters in scale. Timely international medical relief efforts are often difficult to manage without an existing infrastructure for disaster response. Immediate response encompasses security, search and rescue, provision of water and sanitation, and lifesaving procedures when available.3
Anesthesiologists may not be considered “essential” personnel in US hospital plans for a response to a local disaster8 despite national requirements that have been identified for mass casualty including the capacity to provide emergent surgical stabilization.9 The ability to organize and deploy effective resources within hours after a disaster in the US includes the expertise and provision of anesthesia and profound analgesia,10 – 13 which may be overlooked.10 Anesthesiologists in Europe and the United Kingdom are intimately involved in mass casualty response, trained for this possibility, and key to the provision of definitive on-site life support.14
After a disaster, local medical teams are expected to respond in the immediate phase, but natural disasters, local or international, may damage or overwhelm local response capability.15 The average time for international response efforts from the time of disaster occurrence to time of field hospital operational status is approximately 2 to 3 days16 but these data are from military teams or organizations that have rapid deployment emergency preparedness plans in place. The following time period of days to weeks that encompasses strategic support has little published literature regarding the optimal design of medical care teams or deployment readiness preparation.
The Joint Commission specifies standards related to hospital emergency management20 but there are few benchmarks for preparedness from professional organizations, including the American Society of Anesthesiologists. Allied health professionals who are employed by hospitals have the least amount of training on their role in hospital preparedness and response plans.8 The readiness of anesthesiology department staff with regard to experience, training, psychological preparation, immunizations, necessary equipment determination and procurement, and deployment has not been reported for an international emergency response by nonmilitary personnel.17 Previously published descriptions of anesthetic needs in low-income countries suggest that intraoperative monitoring should be similar to that used in the US.18 However, there is little available literature on standards during a mass casualty response by civilian personnel. Flaws in the management of various aspects of previous earthquake disasters demonstrate defects in personnel selection, available medical supplies, and treatment plans.19 We believe that our university and departmental response was tempered with adequate preparation and appropriate caution while seeking to address the overwhelming needs of Haitians. Although we were not immediate in responding (deployment within 48 hours), our planning process in selecting personnel and medical supplies was very well thought out. A multidisciplinary team (anesthesiology, surgery, perioperative nursing, and pharmacy) worked tirelessly to organize and package the equipment; once in Haiti, most operative cases were performed with general anesthesia (GA), due to both the availability of a ventilator and to the language barrier. Because there was no driving gas for the ventilator and oxygen cylinders were a precious resource, patients were tracheally intubated with succinylcholine then allowed to breathe spontaneously through the procedures. Endotracheal tube GA transitioned over time during the team's mission to primarily laryngeal mask airway GA. With our immunization and prophylaxis program, no returning team members reported an illness or had converted to (+) purified protein derivative tuberculin. Daily pre-deployment team-building sessions and daily evening informal debriefings in Haiti with team members seem to have been effective: team members were offered counseling upon return if needed, but each declined, maintaining support with family and with each other.
Much of the data that are emerging after this crisis were not available to us at the time of planning and preparation for our response.21,22 The recently published Israeli disaster response experience in Haiti was successful because of a well-prepared and trained medical unit maintained on continuous alert and with previous deployments to Turkey, India, Rwanda, and Kosovo.23 A report on lessons from the Wenchuan earthquake describes both a response within a hospital to treat arriving earthquake victims, and the experience of a team sent to the epicenter to provide medical care.24 In addition to the challenges faced by the deployed Chinese response team, such as absence of an emergency generator, water purification system, satellite communication system, and drugs to protect the team from visceral leishmaniasis, there are considerations that we faced in responding to an international natural disaster, such as long-distance transportation challenges, immunization considerations, and security issues. Similar to the Chinese team, we had no preexisting response plan established and have learned from this exercise. Academic health centers can be a valuable resource in preparing teams in advance to allow for rapid deployment of emergency health care teams to respond to medical emergencies. As returning anesthesiology team members have expressed (MA): “Nothing can replace planning, preparation and experience,” and (TF): “Universities and individuals should be preidentified and equipment lists in place, as well as plans for immobilization.” Finally, (TF): “Listen closely to the needs of the team already on site … give them what they need, not what you think they need.”b Supplementing military and civilian emergency response teams with well-prepared medical response teams from academic medical centers may help fulfill health care needs when bridging between the immediate response to a crisis and long-term medical care.
Evaluation should now become a top priority in global health.25 The WHO situational analysis toola was completed by the Penn medical team leader. The tool was found to be inappropriate in its current form because of inapplicability: infrastructure data regarding the number of admissions and population served was in flux in Haiti, human resources were determined by our medical team in addition to in-country providers, and many interventions and the emergency equipment and supplies were provided by the Penn team. This tool could be adapted for use in disaster response situations.
Limitations of this report include the fact that this is a single-center experience and that it is not supported by outcome data. As a follow-up, our returning team members are reporting on the appropriateness of their preparations and the effectiveness of the response. The response of individual anesthesiology departments at academic university medical centers is not known and we have investigated how others reacted (McCunn M, Speck RM, Fleisher LA. Abstract: A RESPOND Survey—Anesthesiology Response Efforts and Strategic Preparedness for Natural Disaster. Accepted to American Society of Anesthesiologists annual meeting, 2010). The development of data collection tools that can be used by medical personnel in this unique environment will be beneficial to future disaster responses.
An organized system for international medical response to a natural disaster emergency can be accomplished safely and effectively by an academic anesthesiology department without an established crisis medical response system within 6 to 12 days. Such efforts should be coordinated with an established medical team with the infrastructure necessary to provide medical care in the disaster area. The value and timeliness of this response will be determined with further study but this may be the ideal timeframe to bridge the gap between emergency response and longer-term relief care.
Thank you to Ms. Carolyn Grous, RN, MSN, CNOR, and Ms. Joan Schafer, RN, BS, CNOR, Department of Peri-operative Nursing; and Mr. Darrell Harris, Department of Anesthesiology, for their help in verifying equipment and medications that were provided.
a World Health Organization. Available at: www.who.int. Accessed July 12, 2010.
b Available at: www.auahq/AUASpring2010.pdf. Accessed May 23, 2010.
1. Zarocostas J. Death toll in Haiti may reach 200,000. BMJ 2010;340:c331
3. Pape JW, Johnson WD, Fitzgerald DW. The earthquake in Haiti: dispatch from Port-au-Prince. N Engl J Med 2010;362:575–7
4. Devi S. Helping earthquake-hit Haiti. Lancet 2010;375:267–8
5. Lorich D, Eachempati S, Helfet DL. Doctors: Haiti medical situation shameful. Available at: CNN.com
. Accessed January 27, 2010
6. Sklar DP, Richards M, Shah M, Roth P. Responding to disasters: academic medical centers' responsibilities and opportunities. Acad Med 2007;82:797–800
8. Markenson RM. Education and training of hospital workers: who are essential personnel during a disaster? Prehosp Disaster Med 2009;24:239–45
9. Brandt EN, Mayer WN, Mason JO, Brown DE, Mahoney LE. Designing a National Disaster Medical System. Public Health Rep 1985;100:455–61
10. Roccaforte JD. The World Trade Center attack: observations from New York's Bellevue Hospital. Crit Care 2001;5:307–9
11. Kirschenbaum L, Keene A, O'Neill P, Westfal R, Asitz ME. The experience at St. Vincent's Hospital, Manhattan, on September 11, 2001: preparedness, response, and lessons learned. Crit Care Med 2005;33:S48–52
12. Jurkovich T. September 11th: the Pentagon disaster—response and lessons learned. Crit Care Nurs Clin North Am 2003;15:143–8
13. Schultz CH, Koenig KL, Noji EK. A medical disaster response to reduce immediate mortality after an earthquake. N Engl J Med 1996;334:438–43
14. Baker DJ, Telion C, Carli P. Multiple casualty incidents: the prehospital role of the anesthesiologist in Europe. Anesthesiol Clin 2007;25:179–88
15. You C, Chen X, Yao L. How China responded to the May 2008 earthquake during the emergency and rescue period. J Public Health Policy 2009;30:379–94
16. Venticinque SG, Grathwohl KW. Critical care in the austere environment: providing exceptional care in unusual places. Crit Care Med 2008;36:S284–91
17. Fitzsimons MG, Sparks JW, Joes SF, Crowley JM, Dalal A, Sunder N. Anesthesia services during operation unified assistance, aboard the USNS Mercy, after the tsunami in Southeast Asia. Mil Med 2007;172:227–31
18. Tobias JD, Kim Y, Davis J. Anesthetic care in developing countries: equipment and techniques. South Med J 2002; 95:239–47
19. Motamedi MH, Saghafinia M, Bararani AH, Panahi F. A reassessment and review of the Bam earthquake five years onward: what was done wrong? Prehosp Disaster Med 2009;24:453–60
21. Pape JW, Deschamps MM, Ford H, Joseph P, Johnson WD, Fitzgerald DW. The GHESKIO refugee camp after the earthquake in Haiti: dispatch 2 fro Port-au-Prince. N Engl J Med 2010;362:e27
22. Sullivan SR, Taylor HOB, Pauyo T, Steer ML. Surgeons' dispatch from Cange, Haiti. N Engl J Med 2010;362:e19
23. Kreiss Y, Merin O, Peleg K, Levy G, Vinker S, Sagi R, Abargel A, Bartal C, Lin G, Bar A, Bar-On E, Schwaber MJ, Ash N. Early disaster response in Haiti: the Israeli field hospital experience. Ann Intern Med 2010;153:45–8
24. Chen G, Lai W, Liu F, Mao Q, Tu F, Wen J, Xiao H, Zhang JC, Zhu T, Chen B, Hu ZY, Li RM, Liang Z, Nie H, Yan H, Yang BX, Du Q, Huang WX, Jiang YW, Kwan AS, Song L, Wu CM, Xiang T, Xu HW, Lau WB, Song HB, Wen CB, Yao ZH, Zhang L, Zeng J, Dai YE, Lopez BL, Zheng JQ, Zhou J, Christopher TA, Ma XL, Yu H, Xu LL, Guo Q, Song ZP, Volinn E, Kryger K, Cao Y, Ge H, Liu H, Luo CZ, Tao W, Zuo YX, Liu J. The dragon strikes: lessons from the Wenchuan earthquake. Anesth Analg 2010;110:908–15
© 2010 International Anesthesia Research Society
25. Evaluation: the top priority for global health. Lancet 2010;375:526