I would like to start out with how touched I was by your short-notice support and advice in the hours
leading up to my departure this past Sunday. I am equally proud and glad to be part of this caring and
supportive medical community!
Although I don't want to single out anyone I have to mention Dr. Elleda Ziemer who went above and
beyond what I was asking for, by individually marking and packaging all medications to the smallest size
possible. In addition she correctly assumed I would have a tough time with any meds other than Ancef
and Vicodin and provided us with a neatly typed-up cheat sheet!! Many, many thanks to all of you!
During my first day back at work I have had many questions asked concerning our experience and in
order to return to move on to productive activity and more pleasant thoughts, I would like to give you a
general account of what we saw and of the current conditions rather than reiterate snap-shot stories
repeatedly in the hallway.
I would sincerely like to emphasize that this is ONLY about the people of Haiti, who are victim to
horrendous circumstances on an epic scale. I feel media coverage so far has been very superficial and
sensational and would like for you to contemplate the implications down the road and future efforts
needed...more on this towards the end.
The broad overview: I cannot think of a comparable humanitarian tragedy in recent history and no
reiteration or images will do justice to what we experienced. This earthquake has not only claimed a
minimum of 50-100 times as many lives as Hurricane Katrina but much more importantly, it has left
double this number of severely injured and crippled human beings in an environment without any
infrastructure. The only secured points in town are the airport and the US embassy, newspaper and TV
reports are obtained in close proximity to these places and do not mirror the horrendous conditions
truly at hand.
The Haitian government is non-functional, the military is securing its footprint and big relief
organizations are amassing goods at the airport without the slightest clue of how to disperse these
goods to the people in need. The main prison was severely damaged and approx. 4000 criminals have
escaped. Water transports and equipment get hijacked only blocks away from the airport by gangs and
the only unimpaired way to transport water to the communities is at this point through children with
A few of you have voiced desire and interest to help in person and at this point I would strongly
discourage these plans unless this is done through military or US government affiliated organizations
with a reliable exit plan. The city is still not secure, private transportation has come to a halt since
military operations has gained control of air-traffic. 90-95% of patients would have required early and
immediate orthopaedic trauma care within the first 24-48 hours, this window has long passed and the
resources required to avert the natural history of these severe injuries are not present or accessible for
this incredible volume of patients. There is ample ground personnel and help organizations present,
however distribution of supplies and overall concerted coordination of these efforts remain the core
problem. Not much has changed since Katrina. Unfortunately, just going there in hope to "just help and
do something" will not alleviate the current situation.
I have added this more detailed account of my impressions: the first-response effort I participated in
was headed by Dr. David Helfet at Hospital for Special Surgery in Manhattan. He left with a crew of 12,
consisting of 2 highly-skilled anaesthesiologists, 4 Orthopaedic Trauma Surgeons/Fellows, 2 scrub
nurses, 1 general trauma surgeon, one nurse practitioner for triage and 2 implant representatives/OR
techs on a corporate jet owned and volunteered by an orthopaedic implant company on Friday
afternoon and was initially diverted to the Dominican Republic. They were able to land on second
attempt Saturday and went to evaluate the Port-au-Prince General Hospital which proved incapacitated
without safe OR facilities, energy or running water. The team went on to find the "Hopital de la
Communaute Haitienne" located in a severely damaged hillside community with intact generators, light
and running water. Two OR's were available with non-functional anaesthesia machines. Patient
intubation/ventilation was not possible, therefore limiting anaesthesia to regional blocks and iv
sedation. The autoclave was the size of a cigar-box. Xray in the OR, ultrasound, ekg monitors, blood
transfusions, labs or intensive care were not available. We had one electrocautery unit for the hospital
and no PACU monitors.
Approximately 700 patients were awaiting evaluation and triage by an international mix of nurses, ER
physicians and community volunteers which all arrived in stages. Spine, pelvis and head injuries were
treated conservatively d/t lack of diagnostics - sink or swim! The team started treatment of the most
critically injured patients with attempts of limb salvage wherever possible by Saturday night. Together
with another Orthopaedic Trauma Surgeon and 4500lbs of equipment I was able to join this team by
We were able to land without problems but found utter chaos at the airport with most reliable guidance
provided by local volunteers for the "Partners in Health" organization. The remnants of Haiti's
governance with their families were escorted onto military planes by U.S. Special Forces and flown out
of the country right in front of our eyes! All of our equipment except a box of saw blades was loaded
onto a truck and directed to our final destination. This truck, sadly, was hijacked on its way and is to this
day not accounted for.
We reached the hospital by private transportation and immediately took over for the 2 teams which
had been operating for 20 hrs straight at that point. Daytime security was provided by 3 Jamaican
soldiers with automatic weapons stationed outside the OR, these troops returned to their base at dusk.
75% of all patients presenting to the hospital presented with open, unreduced and severely comminuted
fractures/dislocations with soft tissue crush injuries, which had been exposed to the environment for a
minimum of 4 days at that point and were (sometimes) immobilized with cardboard or wood planks.
Primary intramedullary fixation without Xray was not feasible, peel-pack military external fixators were
applied where possible. Advanced infection, necrotizing fasciitis, rhabdomyolysis and compartment
syndrome however were most common forms of presentation and an increasing percentage of patients
underwent primary amputation as time from injury increased. The thought of amputating a young girl's
arm for relatively simple wrist fractures seems impossible in this day and age...
Children and pregnant women were prioritized in the triage process. On the second day our team was
able to equip a third room for minor procedures and the 3 surgical teams performed close to 100
procedures (25% with multi-extremity involvement) within a 60-hour period, which was interrupted by
two 2-3hr rest periods while the hospital's generators were shut down for maintenance during the early
morning hours. The patients and their families were incredibly appreciative and thankful for our
presence, despite their obvious pain, exhaustion and devastation and the drastic and life-altering
procedures we had to perform.
Our goal was to work at high intensity until Tuesday 8 PM with a scheduled departure time at 11 PM
with exchange for a fresh team from HSS. By Monday at noon we were able to clear hallways around the
OR and a sense of "catching up" was present. By Monday night the hospital was literally flooded with a
second wave of patients sicker than any of the previously treated, after news had spread that patients
were actually treated at our facility. This necessitated lockdown of all hospital entry points with
understandable discontent of the many who were denied access. By Tuesday morning it became evident
that many previously treated patients required repeat irrigations and debridements and that many of
the new patients were actively septic and/or in multi-organ failure with systemic inflammatory response
syndrome. The hospital's sanitary system failed around this time.
6AM Tuesday morning we received notice that our plane was no longer allowed to land due to massive
military personnel reinforcements. These news really put a severe dent into the team's morale and spirit
as well as our exit plan. Meanwhile, the face of US medicine, Dr. Sanjay Gupta, performed a single,
fortunately successful, neurosurgical procedure onboard the US Comfort, which, 6 days after the
earthquake, was still over a day away from its final destination! And we still had not seen a single US
soldier in over 3 days, despite multiple requests for nighttime security backup with US authorities. We
were unable to keep up our surgical volume because the postoperative patients could no longer be
moved to the overflowing PACU. At this point the first patients started to succumb to their injuries in
the hallway while waiting for surgery.
The next possible landing time for our plane was set for this coming Friday evening and the team
decided at this point that we were not able to maintain care at this pace and keep up with the constant
influx of severe traumas with the available resources and without nighttime protection. Water and food
was also not available in sufficient quantity to sustain till Friday. We decided to look into alternative exit
strategies via the Dominican Republic with an emphasis on daytime travel. By noon, private
transportation was organized by our local contacts and the entire 13-man group incl. gear left for the
airport in the back of a single pick-up truck. Our last procedure was assistance with a C-section and
intubation of a baby which was not breathing on initial evaluation - both child and mother were stable.
I cannot describe the deflation of hope and loss of faith in our patients' eyes when they essentially saw
the entire team walk from the OR to the door, these images and feelings of guilt and abandonment will
stay with me forever. We fortunately were protected by the group of Jamaican soldiers during our
backdoor exit from the hospital.
A French team arrived just prior to our departure and was able to fill our spot. An Orthopaedic surgery
team from St. Thomas and a general/ob-gyn surgeon from Jamaica remain with an US-trained
Orthopaedic Surgeon, who has committed to a long-term effort at this hospital and has kept our
remaining equipment. We were lucky enough to gain access to the tarmac without encountering the
masses lined up outside the airport. A Canadian military pilot was kind enough to help us to get on the
passenger list of a plane headed to Montreal ,where we were able to transfer to our original jet early
What remains is the desire to highlight the dire need for coordinated action on the ground and a change
of approach in future natural disasters of this magnitude - since hurricane Katrina we have not improved
Concerning future efforts: Some of you have kindly volunteered financial help on Saturday which I
gratefully declined prior to my departure since I did not think money would be able to accomplish much
at this point. However, now that I have gained a general idea of the problems the people of Haiti will
face, I would like to set up a foundation and hopefully set up a surgical follow-up program to improve
the lives of a select group of survivors. We were told by many, that amputees have no access to
prosthetic limbs or wheelchairs and are essentially taken care of by their family members until they
succumb with secondary complications.
The November 2009 issue of Time magazine highlighted and praised development and design of the
"Jaipur Knee" as one of 2009's best 50 inventions. A functional prosthesis manufactured from
sustainable and affordable materials for the cost of 20 dollars, assembled and built within hours!
If you have specific knowledge on the business side of charitable institutions, I would like to ask for your
help in setting up a foundation for the future mass of Haiti's amputees. I would also like to encourage
your donations at this point, while the shocking images are still present and before the mass media
shifts its attention back to the Superbowl!
I promise full return of all donations in case we should be unable to launch this project. Along with
delivery of prosthetic devices, I will be looking for a once or twice-a-year "travel team" consisting of a
prosthetist for fitting and customizing these prostheses, an anaethesiologist well versed in regional
anaesthesia along with scrub nurses and OR techs in order to perform post-traumatic reconstructive
procedures for osteomyelitis and non-/malunions.
The Orthopaedic Trauma Association (OTA) has recognized the long-term need for these services and
will coordinate dispatch of these volunteer teams. Credentialing through HHS will be required, I will
keep you posted on specifics if there is enough interest.
I hope you will find this information useful and informative and invite your participation in future
efforts! Along these lines, feel free to pass this on to anyone interested and contact me with any
questions and/or advice at: firstname.lastname@example.org.
Kindest regards, Florian.
Monday, January 25, 2010
A former co-worker sent me this account, written by her husband, and it was sent as an email attachment, so I wasn't able to figure out how to link to it. So, here it is, with permission from the writer, and when I can figure out how to add the pictures, I will: