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Early Disaster Response in Haiti: The Israeli Field Hospital Experience FREE

Yitshak Kreiss, MD, MHA, MPA; Ofer Merin, MD; Kobi Peleg, PhD, MPH; Gad Levy, MD; Shlomo Vinker, MD; Ram Sagi, MD; Avi Abargel, MD, MHA; Carmi Bartal, MD, MPH; Guy Lin, MD; Ariel Bar, MD, MHA; Elhanan Bar-On, MD; Mitchell J. Schwaber, MD, MSc; and Nachman Ash, MD, MS
[+] Article and Author Information

From the Israel Defense Forces Medical Corps Field Hospital, Home Front Command, and Israel Defense Forces Medical Corps Surgeon General; Shaare Zedek Medical Center, Hebrew University, Jerusalem; Israel National Center for Trauma and Emergency Medicine Research, The Gertner Institute for Epidemiology and Health Policy Reasearch, and Chaim Sheba Medical Center, Tel Hashomer; School of Public Health and Sackler School of Medicine, Tel Aviv University, Tel Aviv Sourasky Medical Center, Assaf Harofeh Medical Center, and National Center for Infection Control, Israel Ministry of Health, Tel Aviv; Soroka University Medical Center and Ben-Gurion University of the Negev, Beer-Sheva; The Western Galilee Hospital, Nahariya; and Schneider Children's Medical Center, Petah Tikva, Israel.


Acknowledgment: The authors thank Ms. Esther Eshkol for editorial assistance, Ms. Dorit Tzur and Ms. Estela Drezena-Simhoni for data analysis, and Lieutenant Colonel Dr. Daniel Segura Sanchez of the National Army of Colombia for clinical assistance and collegiality.

Potential Conflicts of Interest: None disclosed. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M10-0522.

Requests for Single Reprints: Yitshak Kreiss, MD, MHA, MPA, 182 Kedem Street, Shoham, PO Box 1773, Israel; e-mail, ykreiss@gmail.com.

Current Author Addresses: Dr. Kreiss: 182 Kedem Street, Shoham, PO Box 1773, Israel.

Dr. Merin: POB 539 Mevaseret, Zion 90805, Israel.

Dr. Peleg: 4 Tomer Street, Reut 71908, Israel.

Dr. Levy: 54 Halivne Street, Givaat-Ada, Israel.

Dr. Vinker: POB 14238 Ashdod, 77041, Israel.

Dr. Sagi: 26 Mishol Haahava Street, Kfar-Sava 44601, Israel.

Dr. Abargel: 21 Hayasmin, Tel-Mond, Israel.

Dr. Bartal: 10 Yamit Street, Beer-Sheba 84803, Israel.

Dr. Lin: Kibbutz Rosh-Hanikra, West Galilee 22825, Israel.

Dr. Bar: 110 Emek Ayalon Street, Modi'in 71700, Israel.

Dr. Bar-On: Pediatric Orthopedic Unit, Schneider Children's Medical Center, 14 Kaplan Street, Petah Tikva 49202, Israel.

Dr. Schwaber: National Center for Infection Control, 6 Weizmann Street, Tel Aviv 64239, Israel.

Dr. Ash: 1st Avital Street, Rosh Haain 48631, Israel.


Ann Intern Med. 2010;153(1):45-48. doi:10.7326/0003-4819-153-1-201007060-00253
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Abstract

The earthquake that struck Haiti in January 2010 caused an estimated 230 000 deaths and injured approximately 250 000 people. The Israel Defense Forces Medical Corps Field Hospital was fully operational on site only 89 hours after the earthquake struck and was capable of providing sophisticated medical care. During the 10 days the hospital was operational, its staff treated 1111 patients, hospitalized 737 patients, and performed 244 operations on 203 patients. The field hospital also served as a referral center for medical teams from other countries that were deployed in the surrounding areas.The key factor that enabled rapid response during the early phase of the disaster from a distance of 6000 miles was a well-prepared and trained medical unit maintained on continuous alert. The prompt deployment of advanced-capability field hospitals is essential in disaster relief, especially in countries with minimal medical infrastructure. The changing medical requirements of people in an earthquake zone dictate that field hospitals be designed to operate with maximum flexibility and versatility regarding triage, staff positioning, treatment priorities, and hospitalization policies. Early coordination with local administrative bodies is indispensable.

An earthquake measuring 7.0 on the Richter magnitude scale struck close to Port-au-Prince, Haiti, on 12 January 2010. The official death toll was set at 230 000, and local authorities estimated that 250 000 people were injured (1). This catastrophic event galvanized a strong and rapid response worldwide, and the Israeli government quickly decided to launch a medical humanitarian mission to provide medical care as advanced as possible under the circumstances.

Whereas the fate of patients with life-threatening internal-organ injuries is determined within the first hours of a disaster, early provision of treatment for the multitudes of patients with open fractures can prevent life-threatening sepsis and limb-threatening infections. In addition, situations involving substantial casualties combined with extensive damage to local medical facilities and infrastructure highlight the need for a resourceful, experienced, and trained medical team backed by a logistics contingent. The Israel Defense Forces Medical Corps (IDF-MC) Field Hospital comprises such a unit (25).

The field hospital staff consisted of 121 servicemen and servicewomen (Appendix Table 1) and was organized into medical, surgical, orthopedic, pediatric, gynecologic, and ambulatory care divisions, as well as auxiliary units (Appendix Figure), with a capacity of 60 inpatient beds that could be expanded to 72.

Table Jump PlaceholderAppendix Table 1.  Composition of Hospital Personnel

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Appendix Figure.
Organizational chart of the field hospital.

The hospital was divided into 7 major divisions: medicine, surgery, orthopedics, pediatrics, obstetrics and gynecology, ambulatory outpatient clinic, and an auxiliary services unit. The surgical division was also responsible for staffing the triage point. The pediatric division included a neonatal intensive care unit, and the obstetrics and gynecology division operated a labor room that also functioned as an obstetric operating room. ED = emergency department.

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To ensure maximum logistic independence and to shorten the time to deployment, we brought all hospital supplies; a fully stocked pharmacy, including sufficient oral antibiotics to be distributed on discharge; imaging machinery; a laboratory that could perform blood tests and urine chemistry, hematology, blood gases, and microbiology analyses; and autoclaves for sterilization. Energy sources (generators) and accommodations (tents and latrines) were also brought from Israel. This crucial effort was carried out by a highly trained, skilled logistics unit of 109 personnel, including computer and communication specialists, security staff, kitchen staff, carpenters, plumbers, mechanics, electricians, and a burial team.

A total of 1111 patients, 44% male, passed through our triage point (Appendix Table 2), of whom 737 patients (63%) were hospitalized. We performed a total of 244 surgical procedures on 203 patients (Appendix Table 3). Trauma accounted for 66% of the admissions; most cases involved open or closed limb fractures. Many patients sustained local or systemic infections involving inadequately treated deep wounds, including necrotizing soft-tissue infections (such as gas gangrene) (Appendix Table 4). During the first 3 days, approximately 80% of the patients seen had had trauma (Figure 1). Hence, all of the hospital resources were initially dedicated to orthopedic procedures (debridement of necrotic tissues in life-threatening infections; fracture fixation for salvageable limbs; and amputation of nonsalvageable limbs, with the aim of saving life). This protocol gradually changed given the dynamic nature of the needs of patients in the earthquake region, resulting in other types of patients being hospitalized (Figure 1).

Table Jump PlaceholderAppendix Table 2.  Distribution of Patients, by Sex and Age

Table Jump PlaceholderAppendix Table 3.  Key Operational Parameters

Table Jump PlaceholderAppendix Table 4.  Occurrence of the Top 10 Most Frequent Trauma Diagnosis Groups

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Figure 1.
Distribution of trauma versus nontrauma cases.

The graph demonstrates the gradual change in case mix over time. Care of trauma patients made up most of the hospital activity in the early days, whereas the percentage of nontrauma patients gradually increased over time.

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The first goal of the IDF-MC is to arrive at a very early stage after a disaster. To do so after the Haitian earthquake, every effort was made to follow a protocol that had been established as a result of our experiences after the earthquakes in Turkey (Adapazari, 1999) and India (Gujarat, 2001) and in humanitarian missions to Rwanda (1994) and Kosovo (Brazda, Macedonia, 1999) (25). We covered the 6000-mile distance to set up a fully operational field hospital within only 89 hours of the event. A special assessment team was en route to Haiti 11 hours after news of the earthquake reached Israel (Figure 2). At the same time, we began organizing the field hospital according to established protocol and landed in Haiti on the evening of 15 January 2010. We chose a deployment area in a soccer field near the airport, and the hospital was fully operational 8 hours after all of the equipment was delivered to the site (Figure 3).

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Figure 2.
Timeline from earthquake to operational deployment.

Dates and times shown are according to Haitian time. The first patient was admitted 89 hours after the earthquake.

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Figure 3.
An aerial photograph of the field hospital.

The tents on the periphery of the setup were used as accommodations for members of the mission. ICU = intensive care unit; Lab = laboratory; OB and GYN = obstetrics and gynecology; OR = operating room.

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Although several factors in the Israeli model enabled this rapid and effective response, the primary factor was the Israeli government's strategic decision that the IDF-MC maintain constant readiness in dispatching a field hospital to anywhere in the world with minimal notice. Major time-saving factors were the high level of preparedness, expressed by staff experience; the “on-alert” mentality of the IDF-MC reserve personnel; intensive training; and that established procedures were followed. Moreover, in the Haiti mission, quick decision making and personal involvement of senior army and government leadership removed substantial obstacles, such as switching from smaller military planes usually deployed to the larger commercial aircrafts required for such a massive and remote disaster. The quick departure of the forward-assessment team and its actions on the ground were also crucial. Their success in enabling our landing in Port-au-Prince and preparing a suitable deployment area saved valuable time.

We needed to decide which would be the optimal type of field hospital to erect in response to the earthquake. The options included a “light” hospital that would provide primary treatment to many patients, or alternatively a more sophisticated hospital with advanced capabilities from a wide variety of specialties that would limit the number of potentially treatable victims. Our choice of the latter option was based on experience with disasters in general and earthquakes in particular. Local hospital infrastructure is often destroyed, as documented in earthquakes in Tangshan, China (1976) (6); Armenia (1988) (7); and Kobe, Japan (1995) (89). Many victims who need hospital-level care require evacuation either to facilities outside the affected region or to mobile hospitals deployed locally that can handle such injuries. In addition, given the nature of earthquake-related injuries, specialized field hospital services that become available only 1 week or more after an earthquake tend to be ineffective in reducing mortality (1011). The United Nations Disaster Assessment and Coordination (UNDAC) reports and personal communications clearly indicated that there was no local medical infrastructure to serve as a referral center and that no field hospital already deployed in Haiti had advanced capabilities (such as intensive care unit, imaging, and laboratory facilities). Furthermore, we understood that delegations expected to arrive would be bringing light hospitals and clinical facilities; therefore, we decided to transport a sophisticated field hospital capable of providing advanced care. We expected that the light hospitals and clinics could care for the vast majority of patients and that we could provide most of the functions of an acute-care hospital. That decision turned out to be appropriate in Haiti, but in retrospect, we recommend that for optimal efficiency, such decisions should lie in the hands of UNDAC or another responsible agency with access to immediate input on all types of medical facilities and personnel deployed to specific disaster areas.

Another challenge we faced was how to deal with the need for surge capacity in our field hospital. As soon as the hospital was deployed, patients began to arrive, as news of the existence of our facility began to spread—largely by word of mouth. In fewer than 2 days, the hospital was at full capacity—more quickly than we had anticipated—in part because it began to serve also as a referral center for the other primary care teams that were deployed in the surroundings and because of the scarcity of advanced medical facilities. We could not continue to admit patients who needed surgery or advanced procedures after our hospitalization capability was fully utilized. To cope with this extremely frustrating situation, we accepted new patients as soon as space became available, performed essential surgery, and discharged the patients sooner than we would have wanted to make room for new arrivals. Because there was no centralized triage mechanism that could direct patients to one facility versus another, and being well aware of the risks of not providing adequate postoperative care, we notified each light hospital and other health facilities that for every patient referred to us for a higher level of care, we would expect the referring facility to be willing to accept one of our patients for immediate postoperative management in exchange. This policy enabled us to maximize the throughput of our operating room by increasing the number of operations and procedures that we were in a unique position to perform, while ensuring that our patients were not abandoned. This kind of optimization of resources, with centralized triage and coordination mechanisms, should also ideally have been under the auspices of an all-encompassing administrative body, such as UNDAC.

We coped with changes in the medical requirements of an earthquake zone over time. The first few days required us to concentrate our efforts on treating injuries caused directly by the earthquake, and so we transformed one orthopedic treatment station into a surgical unit with full anesthetic and monitoring capabilities, thus doubling our surgical capacity. We also shifted medical staff members, especially nurses, from nonsurgical units to general and orthopedic surgery units. At the time of peak pressure, a Colombian military surgical team was incorporated into our staff; as a result, 3 to 4 operating tables were occupied around the clock. A few days later, when patients with less urgent medical needs began arriving, we again readjusted staff assignments, organization of the units, and the policy of hospitalization. Such intramission adaptability, we have learned, is possible only when there is maximal versatility in staff selection and training, implementation of equipment, and organizational planning.

Disaster medicine always involves ethical issues, and these were especially challenging in Haiti given the huge discrepancy between available resources and human need. We confronted numerous clinical and ethical dilemmas that we rarely encounter in daily clinical practice. They began as early as triage—for example, in deciding which patients we could accept with our limited resources—and continued throughout our stay (12). The World Medical Association recommendations on medical ethics in the event of disasters include the following statement: “The physician must act according to the needs of patients and the resources available. He/she should attempt to set an order of priorities for treatment that will save the greatest number of lives and restrict morbidity to a minimum” (13). This guideline led us to prioritize the provision of treatment to Haitian patients with life-threatening conditions in a way that would allow us to extend our resources to the maximum number of people in need. Specifically, on the basis of this approach, patients receiving care were not necessarily the most severely injured but were those deemed most likely to benefit from treatment. Medical leaders and personnel must be prepared to confront these complex ethical decisions.

During our deployment in Haiti, humanitarian delegations from many other countries, nongovernmental organizations, and the United Nations continued to arrive. The increasing hospitalization capacity of The General Hospital operated by the Red Cross (the largest local hospital), the arrival of the hospital ship USNS COMFORT, and the establishment of a medical facility by the University of Miami allowed provision of longer-term medical care, thereby permitting us to coordinate an orderly transfer of patients and departure from Haiti with a sense of our mission having been accomplished. It is our hope that the lessons we learned in responding to the Haitian disaster will be translated into internationally accepted recommendations, and that these in turn will never in the future need to be implemented.

References

Médecins Sans Frontières.  Haiti: from one emergency to the next. London: Médecins Sans Frontières; 12 February 2010. Accessed atwww.msf.org.uk/haiti_one_month_on_20100212.newson 15 April 2010.
 
Amital H, Alkan ML, Adler J, Kriess I, Levi Y.  Israeli Defense Forces Medical Corps humanitarian mission for Kosovo's refugees. Prehosp Disaster Med. 2003; 18:301-5. PubMed
 
Heyman SN, Eldad A, Wiener M.  Airborne field hospital in disaster area: lessons from Armenia (1988) and Rwanda (1994). Prehosp Disaster Med. 1998; 13:21-8. PubMed
 
Bar-Dayan Y, Leiba A, Beard P, Mankuta D, Engelhart D, Beer Y, et al..  A multidisciplinary field hospital as a substitute for medical hospital care in the aftermath of an earthquake: the experience of the Israeli Defense Forces Field Hospital in Duzce, Turkey, 1999. Prehosp Disaster Med. 2005; 20:103-6. PubMed
 
Bar-Dayan Y, Beard P, Mankuta D, Finestone A, Wolf Y, Gruzman C, et al..  An earthquake disaster in Turkey: an overview of the experience of the Israeli Defence Forces Field Hospital in Adapazari. Disasters. 2000; 24:262-70. PubMed
CrossRef
 
Sheng ZY.  Medical support in the Tangshan earthquake: a review of the management of mass casualties and certain major injuries. J Trauma. 1987; 27:1130-5. PubMed
 
Noji EK, Kelen GD, Armenian HK, Oganessian A, Jones NP, Sivertson KT.  The 1988 earthquake in Soviet Armenia: a case study. Ann Emerg Med. 1990; 19:891-7. PubMed
 
Tanaka K.  The Kobe earthquake: the system response. A disaster report from Japan. Eur J Emerg Med. 1996; 3:263-9. PubMed
 
Aoki N, Nishimura A, Pretto EA, Sugimoto K, Beck JR, Fukui T.  Survival and cost analysis of fatalities of the Kobe earthquake in Japan. Prehosp Emerg Care. 2004; 8:217-22. PubMed
 
Adler J, Eldar R.  [Recommendations for earthquake preparedness in Israel]. Harefuah. 2001; 140. PubMed
 
Schultz CH, Koenig KL, Noji EK.  A medical disaster response to reduce immediate mortality after an earthquake. N Engl J Med. 1996; 334:438-44. PubMed
 
Merin O, Ash N, Levy G, Schwaber MJ, Kreiss Y.  The Israeli field hospital in Haiti—ethical dilemmas in early disaster response. N Engl J Med. 2010; 362:38. PubMed
 
World Medical Association.  Statement on Medical Ethics in the Event of Disasters. 14 October 2006. Accessed atwww.wma.net/en/30publications/10policies/d7/index.htmlon 15 April 2010.
 

Figures

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Appendix Figure.
Organizational chart of the field hospital.

The hospital was divided into 7 major divisions: medicine, surgery, orthopedics, pediatrics, obstetrics and gynecology, ambulatory outpatient clinic, and an auxiliary services unit. The surgical division was also responsible for staffing the triage point. The pediatric division included a neonatal intensive care unit, and the obstetrics and gynecology division operated a labor room that also functioned as an obstetric operating room. ED = emergency department.

Grahic Jump Location
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Figure 1.
Distribution of trauma versus nontrauma cases.

The graph demonstrates the gradual change in case mix over time. Care of trauma patients made up most of the hospital activity in the early days, whereas the percentage of nontrauma patients gradually increased over time.

Grahic Jump Location
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Figure 2.
Timeline from earthquake to operational deployment.

Dates and times shown are according to Haitian time. The first patient was admitted 89 hours after the earthquake.

Grahic Jump Location
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Figure 3.
An aerial photograph of the field hospital.

The tents on the periphery of the setup were used as accommodations for members of the mission. ICU = intensive care unit; Lab = laboratory; OB and GYN = obstetrics and gynecology; OR = operating room.

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Tables

Table Jump PlaceholderAppendix Table 1.  Composition of Hospital Personnel
Table Jump PlaceholderAppendix Table 2.  Distribution of Patients, by Sex and Age
Table Jump PlaceholderAppendix Table 3.  Key Operational Parameters
Table Jump PlaceholderAppendix Table 4.  Occurrence of the Top 10 Most Frequent Trauma Diagnosis Groups

References

Médecins Sans Frontières.  Haiti: from one emergency to the next. London: Médecins Sans Frontières; 12 February 2010. Accessed atwww.msf.org.uk/haiti_one_month_on_20100212.newson 15 April 2010.
 
Amital H, Alkan ML, Adler J, Kriess I, Levi Y.  Israeli Defense Forces Medical Corps humanitarian mission for Kosovo's refugees. Prehosp Disaster Med. 2003; 18:301-5. PubMed
 
Heyman SN, Eldad A, Wiener M.  Airborne field hospital in disaster area: lessons from Armenia (1988) and Rwanda (1994). Prehosp Disaster Med. 1998; 13:21-8. PubMed
 
Bar-Dayan Y, Leiba A, Beard P, Mankuta D, Engelhart D, Beer Y, et al..  A multidisciplinary field hospital as a substitute for medical hospital care in the aftermath of an earthquake: the experience of the Israeli Defense Forces Field Hospital in Duzce, Turkey, 1999. Prehosp Disaster Med. 2005; 20:103-6. PubMed
 
Bar-Dayan Y, Beard P, Mankuta D, Finestone A, Wolf Y, Gruzman C, et al..  An earthquake disaster in Turkey: an overview of the experience of the Israeli Defence Forces Field Hospital in Adapazari. Disasters. 2000; 24:262-70. PubMed
CrossRef
 
Sheng ZY.  Medical support in the Tangshan earthquake: a review of the management of mass casualties and certain major injuries. J Trauma. 1987; 27:1130-5. PubMed
 
Noji EK, Kelen GD, Armenian HK, Oganessian A, Jones NP, Sivertson KT.  The 1988 earthquake in Soviet Armenia: a case study. Ann Emerg Med. 1990; 19:891-7. PubMed
 
Tanaka K.  The Kobe earthquake: the system response. A disaster report from Japan. Eur J Emerg Med. 1996; 3:263-9. PubMed
 
Aoki N, Nishimura A, Pretto EA, Sugimoto K, Beck JR, Fukui T.  Survival and cost analysis of fatalities of the Kobe earthquake in Japan. Prehosp Emerg Care. 2004; 8:217-22. PubMed
 
Adler J, Eldar R.  [Recommendations for earthquake preparedness in Israel]. Harefuah. 2001; 140. PubMed
 
Schultz CH, Koenig KL, Noji EK.  A medical disaster response to reduce immediate mortality after an earthquake. N Engl J Med. 1996; 334:438-44. PubMed
 
Merin O, Ash N, Levy G, Schwaber MJ, Kreiss Y.  The Israeli field hospital in Haiti—ethical dilemmas in early disaster response. N Engl J Med. 2010; 362:38. PubMed
 
World Medical Association.  Statement on Medical Ethics in the Event of Disasters. 14 October 2006. Accessed atwww.wma.net/en/30publications/10policies/d7/index.htmlon 15 April 2010.
 

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