One cannot be truly ready for what the eye sees and the heart feels when you walk amidst the tragedy in Haiti. And, trying to harden, or steel, the senses of the providers against what they will behold is difficult – perhaps impossible. All we can do is be absolutely clear in what they will see and absolute in what they will feel.
I will attempt to create an outline – listing first what to expect (the challenges), and then some suggestions for getting through it (the mitigation).
Confusion, almost disorientation, and an overwhelming sense of ‘how can anyone really help’ – these sensations are frequently mentioned by providers when they are debriefed. Our providers, all trained to work as deployed teams, were familiar with the domestic response. They understood supply chain variability, living and working in tents, sleeping on cots, using mosquito netting and repellent. They had trained to work around the dust and dirt of the ground, the never ending sound of the electrical generators, and the limitations of a restricted water supply. Many had experienced the look their patients would have as the realization of being ill or injured worked through their consciousness and combined with their loss of home, loved ones, and family treasures, heirlooms, and memorabilia passed down through the family as mementos and keepsakes. What the providers lacked was experience with a supply chain that stretched to another country. Most had never witnessed piles of boxes and equipment sitting on the ground near a runway – ready for locals with trucks to drive up and pillage. Security and transportation were never totally ‘assumed’ before – but they always seemed to be there. This was not the case in Haiti.
Whatever you needed in Haiti, you had to either bring with you, or have a well worked out logistics chain back to the States. Those NGOs that managed to set up healthcare locations without considering this basic truth, quickly found themselves – in the best case – unable to provide anything more than first aid; and in the worst case, they became ‘victims’ themselves – or at least a burden or drain on the limited resources.
So the first lesson is – be part of a bigger organization that can support you and your mission. Don’t take 5 or 10 of your buddies and all the supplies you can pack up and charter a flight. You are going to be more of a problem than a solution.
Then there is the issue of the incredible sense of isolation of having no where to send (refer) your most serious patients. The medical infrastructure was in shambles. Communications to referral centers were frequently not available and when available, simply provided wrong information. The Haitian Ministry of Health primary building (like almost all the government offices) was in ruins. The government and medical facilities lost buildings, equipment, supplies, communication, staff members and, for those survivors, family members. The fact that they could function at any level was a testament to their courage and dedication.
The US Navy and the US Department of Health & Human Services attempted to survey and catalog the facilities that were still able to provide care and both the level of that care and availability of specialty care. However, the results were conflicting and seemed to change daily or even hourly. The typical referral system with which US providers had experience, i.e., call a facility to get an accepting physician, simply did not work. What eventually did work was to work closely with a limited number of facilities, get the cell phone numbers of a few specialty providers, and call them directly.
Developing a referral system, working that system, and actually transferring patients (which included obtaining vehicles, drivers, and security) requires a fairly well connected organization. Again, my emphasis on not trying to do it small. Be somehow connected to a bigger organization with, hopefully, international backing – including a referral pathway to another country.
Success, even limited success, required organizational support, money, transportation, security, and a referral system that you help create and manage. Then there is the issue of ‘standards of care’.
For the local physicians and many of the NGOs, because of the environment, the lack of supplies, the absence of a referral system, poor communications, and absent or inadequate security and transportation, the standard of care that providers were used to was non-existent. Providers cannot rely on simply transferring patients to other countries – including the United States. One becomes inundated with patients that should be treated with the latest generation of antibiotics, yet those antibiotics are nowhere to be found. The patient needs an ophthalmic referral for globe laceration, yet you can find no one who knows anyone who is an ophthalmologist – at least with equipment and supplies. The infant presents with ‘failure to thrive’. You suspect congenital heart disease but have no ultrasound. Or perhaps worse, you get an ultrasound and find Tetralogy of Fallot – but have absolutely no way to treat and therefore are faced with telling the mother that, without surgery, her child will unlikely live pass their 20th birthday.
In an environment of severe trauma, e.g., a post earthquake scenario, amputations were commonplace because skin grafts were not available. Infection, if present, was treated with massive doses of whatever antibiotic you happened to be able to obtain. Kidney failure from crushed muscles was simply not treatable.
So how does one cope with working in an environment of standards of care that are remarkably different (worse) than what one is used to? Here is what we saw that reflected the inability to deal effectively. We saw anger to the point of rage – followed by, or preceded by, incredible frustration. We witnessed providers threatening to call the media in an attempt to change their environment. Providers packed up and left. Some cried.
How would anyone prepare for those feelings?
Again, be part of a bigger system. Stay for no longer than two weeks, and then rotate out for at least a month. Be healthy before you decide to deploy into the environment. Get your immunizations and sufficient routine medication for yourself – and don’t forget to take them while deployed. Have an inviolate work/rest cycle. It was hot – stay hydrated. It was dirty – do your best to stay clean. If you have significant health issues and/or are obese or have mobility challenges (wheelchair, crutches, even a cane), do not deploy. Finally, as you redeploy (return home) you must have an opportunity to talk to a counselor about what you’ve seen and how you feel about it. I found that I felt incredibly guilty that I was returning home when there was so much to still accomplish.
In summary, be healthy or don’t go. Be part of a large, well supported system, or don’t go. Return home after two weeks and do not return for at least a month. Be as mentally prepared as you possibly can to have patients that, ‘back home’ you’d have no problem treating – but in Haiti you’ll let them die or remove their limb or eye, or leave them tremendously disfigured. And, lastly, participate in a debriefing upon departing that permits you to examine your feelings.