Haitian Patients Receive Help From U.S. Hospitalists
When Dr. Lisa V. Luly-Rivera admitted the 14-year-old girl to the University of Miami's tent hospital at the airport in Port-au-Prince, the girl's leg was edematous and she had some hyperpigmentation. But between one day and the next, her leg became warm, and the warmth started moving up toward her thigh. The leg was clearly infected.
The surgeons, fearing necrotizing fasciitis, wanted to amputate. Dr. Luly-Rivera, a hospitalist at the University of Miami who was in Haiti to help earthquake victims, found herself arguing with the surgeons.
“No, that's not what you do and you know it,” she recalls saying. “You don't just have to preemptively amputate.”
She pointed out that the girl could still move her leg, and it had some range of motion. She knew she had some good antibiotics—Rocephin, Flagyl, and Clindal—to provide multiorganism coverage. So she insisted that the surgeons do a fasciotomy. Then she treated the girl with IV antibiotics and hoped the infection would abate. It did, and the girl kept her leg.
Dr. Luly-Rivera arrived in Haiti just 8 days after the devastating earthquake on Jan. 12, 2010. A Haitian-American who was born in Queens, N.Y., Dr. Luly-Rivera has many friends and relatives still living in that poverty-stricken country, and fortunately none was seriously hurt. But she knew that her skills as a hospitalist—and the fact that she spoke fluent Creole—could be put to good use during her 5-day visit.
She wasn't alone. The University of Miami Leonard M. Miller School of Medicine has had a presence in Haiti since 1994 through Project Medishare, a program founded by Dr. Barth Green and Dr. Arthur Fournier. University physicians quickly organized into teams that would spend 5 days in Haiti providing emergency medical and surgical care.
At first they set up a hospital at a United Nations facility, but just a day after Dr. Luly-Rivera and her hospitalist colleague Dr. Amir K. Jaffer arrived, the university constructed a field hospital at the Port-au-Prince airport. The hospital, in four large tents with three operating rooms, was equipped to handle 250 patients.
Two days after the field hospital opened, the first radiology machine arrived. “Patients were already getting amputations in the operating room for injuries that were not likely to heal or that were leading to wound infections or compartment syndromes,” Dr. Jaffer recalled. “But those where the fractures were more occult, where they were not visible but they still had a lot of pain, they were splinted and stabilized. And then they started to get casts when we had an x-ray machine available on-site.”
Dr. Jaffer, who has special expertise in deep vein thrombosis (DVT), was glad to see that the hospital had heparin and low-molecular-weight heparin. Many patients had fractures of a long bone, so Dr. Jaffer started these high-risk patients on prophylaxis.
Dr. Jaffer and Dr. Luly-Rivera both said they did anything that needed doing, from starting IV lines to bringing food to patients. But they also used their training as hospitalists to comanage patients along with the surgeons. The hospitalists managed patients' fluids, pain, and antibiotics.
They worked in shifts that were nominally 12 hours long, but sometimes ended up lasting 15 or even 20 hours. During a night shift, Dr. Luly-Rivera noticed something strange about a 17-year-old boy she had admitted the day before. The boy had a hemopneumothorax, but no chest tubes were available, so the surgeons had improvised one with a Foley catheter and some surgical tubing.
That night Dr. Luly-Rivera noticed the boy was lethargic and unresponsive, although she recalled he had been able to follow commands earlier in the day. “I said to myself, 'OK, we don't have all of the resources here. We have to send him to the Israeli hospital [which was better equipped].' So I woke up the entire surgical team,” she said. “I said, 'This patient is going to crash tonight if we don't transfer him.' And everyone started arguing: 'We don't have security.' 'How are we going to transfer him over?' 'Well, he's not crashing right now.' And I said, 'He will die tonight if we don't do something.'”
Dr. Luly-Rivera found some of the EMTs who were there from Miami, who agreed to have the boy transferred to the Israeli hospital, where he got a proper chest tube. “He was so critical that they shipped him to the U.S.N.S. Comfort [the U.S. Navy's hospital ship docked at the waterfront]. I just got a report back on Tuesday. He's doing much better.”
Dr. Luly-Rivera expressed mixed emotions about her experience in Haiti. At first she said, “I enjoyed my time down there,” but a minute later she said, “It was extremely difficult to witness what was going on … and to see the suffering of the patients. It was difficult to see all the children being amputated, the adults. I just left there with the sense of, what's going to happen to this generation of people? It was very disheartening.”
