Shaky Start

When US physicians first arrived in Haiti, they had few resources; then much-needed portable and mobile imaging equipment arrived.

A day after arriving in post-earthquake Haiti, Mark D. Pearlmutter, MD, FACEP, treated a case of tetanus. The Boston-based physician had only seen the condition in textbooks, but now a 4-year-old girl lay in front of him with signs of the infection that is all but a memory in first-world countries.

After treatment with antibiotics and wound debridement, Pearlmutter eventually had to intubate her and keep her breathing by squeezing an ?antique ambu bag.? Keeping a steady cadence on the bag, he and the child boarded a Navy helicopter bound for specialty care at the US Navy?s Hope, a boat in the Port-au-Prince harbor. Pearlmutter later wrote in his journal that as he ran the child across a soccer field/converted helipad, ?my singular thought was that this young girl could survive and possibly lead an entirely normal life.?

After dropping the girl off, Pearlmutter nabbed a brief bit of solace as the helicopter glided back to the makeshift medical facility, passing over the mountainous terrain and lush valleys of the Caribbean nation that is slightly smaller than Maryland. As chair and vice president for Network Emergency Services at Caritas Christi Health Care, Pearlmutter was making his first rescue mission as a treating physician. He had taken organizational roles in previous disasters, but this was hands-on work with patients.

As an assistant professor of emergency medicine at the Tufts University School of Medicine, Pearlmutter teaches his students to selectively rely on sophisticated medical imaging equipment, a commodity in short supply in any third-world country. Unlike many physicians who traveled to Haiti, he considered himself lucky to work in an intact hospital with an adjacent school for housing patients.

The hospital, however, did not have the imaging capabilities needed for optimal diagnoses. ?Before we received ultrasound, two C-arms, and digital imaging capabilities from Philips, we used some archaic methods,? said Pearlmutter, a physician since the late 1980s. ?It was plain film that required hand dipping in the various chemicals. It worked, but it was tedious.?

Open Fractures

The bone-crushing moments that transformed Haiti into a sea of rubble took many lives and caused countless fractures. Pearlmutter arrived 8 days after the major quake, and even after that much time, he and his colleagues were receiving patients with open fractures. ?Bones were still protruding,? said Pearlmutter, who stayed in the country for 2 weeks. ?We were receiving burn patients who had yet to receive any treatment. We received paralyzed patients. I would venture to say every patient we saw had serious injuries during that first week we were there.?

Prolonged exposure to contamination led to serious infections. Victims being evacuated or freed from dusty confines were essentially put in the queue as helicopters lifted as many as could be transported to various destinations?all receiving only basic first aid on site. ?Wounds were mostly wrapped in makeshift bandages, and when we unwrapped the bandages, we were horrified to find the injuries,? said Pearlmutter. ?Four out of five were very serious injuries. If we encountered just one of these cases at home, the injury would ultimately be discussed in staff meetings, but here we probably had 150 to 200 cases all arriving within about a week and a half.?

Experience as an emergency physician helped in the ?totally chaotic? scene that Pearlmutter experienced, but the sheer magnitude of misery dwarfed anything he had seen in the States. ?Catastrophic injuries were everywhere, and it was overwhelming,? lamented Pearlmutter. ?It was difficult to sort who should go to the operating room first, because they all needed to go. If any one of these 150 patients arrived in the United States in an emergency department, they would immediately go to the OR. But here some of them had to wait 3, 4, or 5 days after already waiting 7 to 10 days.?

Urgent Need for X-ray

In what amounts to an extension of Port-au-Prince, the town of Carrefour eventually became the staging area for David M. Reed, MD, MPH, MBA, FACS, a surgeon with Stamford Hospital, Stamford, Conn. The quake toppled up to half of Carrefour?s buildings in the worst hit sections, so Reed set up shop in an open disco dance school behind a hotel. ?We pitched our tents on the dance floor, then took tables and set up our medical supplies,? said Reed, a veteran of far-flung medical relief work since 1987. ?There was a door in the back that led to a covered alley with an entrance, and that is where we set up our clinic.?

The shelter had a tin roof and was basically open with an 8-foot wall. Despite the primitive setup, the structure was still standing and relatively secure, a crucial attribute considering that aftershocks were always a possibility. They lived and ate in the facility, and the clinic was steps away. Rooms amounted to plywood barriers turned on their side with sheets hung on string.

With the help of five Haitian nurses, Reed and his colleagues saw more than 700 patients in a 6-day span. Reed?s nurse, Ann Giuli, could treat the less severe cases, while Reed tended to complex problems.

After visiting three different earthquake sites in other countries over the years, Reed knew he would need an x-ray machine. Similar to times past, he did not have one in Haiti. ?I was putting on casts with no x-ray, and it?s not a good situation,? said Reed. ?I contacted Pam Kowalski, our Haiti coordinator for the hospital back home, who called our chief radiologic technologist David Fine. David had a contact at Fuji, and within 6 hours Fuji agreed to donate a $200,000 state-of-the-art, digital, battery-powered machine.?

Knowing the new machine was on its way buoyed spirits, but did little to help Reed who confesses he was often practicing 21st-century medicine with 19th-century technology. Without imaging, he was forced to rely on a keen visual exam and his well-honed instincts. ?Down there, all you have is your exam,? said Reed, who has participated in relief work in various locales including Kuwait, Honduras, Iran, and Russia. ?You don?t have labs or x-rays, and you have to figure it out with your basic knowledge, sometimes from as far back as medical school?not technology. I am sure I missed stuff, but it?s better than the alternative, which is nothing.?

Reed recalls an 8-year-old boy who required a cast. Reed set the fracture as an American fireman acted as his assistant to squeeze it and try to get alignment. ?That?s where it would be really helpful to have an x-ray to see that you have a reduction, since you don?t know what it looked like before and you don?t know what it looks like now,? said Reed. ?Fortunately, a lot of things do heal, particularly in kids. You?ve got to do the best you can. You make do.?

After making do in so many locations torn by war or Mother Nature, Reed continues to travel both domestically and abroad for reasons that have a lot to do with personal growth, and the satisfaction of making a contribution. ?I go because I always get as much out of it, if not more, than anyone else,? said Reed. ?It?s about enjoying a challenge. It?s kind of the reason I got into medicine in the first place. It always renews my faith. You can get cynical when the HMOs beat you down or Medicare is hassling you.

?When you do something like this, you think, ?What am I worried about? I?ve got everything I need to practice medicine. I?ve got a great family and a good life here,?? said Reed. ?It always puts things in perspective. It keeps you grounded.?

Pitching In

American businesses and hospitals pulled together to help US physicians help Haiti. A local construction company made it possible for Pearlmutter and his Caritas colleagues to take a private plane to Haiti. At Reed?s Stamford Hospital home base, administrators allowed him to go down to central supply and raid the cupboards. Meanwhile, several medical imaging manufacturers, such as Carestream Health Inc, Philips Healthcare, Siemens Healthcare, and Fujifilm Medical Systems USA, all donated crucial equipment.

Siemens, for example, donated 20 ACUSON P10 ultrasound systems. The handheld devices are well suited for the urgent medical needs in Haiti as they were designed for triage and emergency situations. In the case of Rochester, NY-based Carestream, officials not only sent its CR-ITX 560 mobile x-ray system, but also Jack Williams, a company service engineer who traveled with the unit. After suffering through some frustrating red tape, Williams accompanied the unit to a tent city medical compound located at the end of the airport runway in Port-au-Prince.

The unit weighs about 1,000 pounds, and Carestream officials did not want to risk sending the machinery without a qualified engineer who could ensure that things went smoothly. ?When we got down there, the physicians had patients who probably had been waiting a week for x-rays,? said Williams. ?For the 3 days I was there, I only saw daylight for an hour a day, and that was when I went out to get something to eat for lunch. Most of the time you worked from 7 am until midnight or 1 in the morning. We were trying to serve as many patients as we could. We were in there helping the physicians do x-rays.?

Out of approximately 180 patients x-rayed, Williams reports that only three did not have fractures. Many had multiple fractures. Thanks to an interpreter who could speak English and the native Creole, things went relatively smoothly. ?Most of the Haitians were exceptionally tough,? reported Williams. ?I remember one who had a pelvis fracture, and she was not even moaning and groaning. Another patient had a leg that was fractured in probably 10 places. The physician said it was the worst he had ever seen in his life.?

Among the triumphs and tragedies that accompany a large-scale disaster, it?s often the personal anecdotes that linger. For Pearlmutter, the girl with tetanus represents the tragic side of the story, because ultimately the little one with the ?sad penetrating eyes? died within 24 hours of arriving at the Navy facility. ?Although we had this young girl in our hearts and minds, we had not yet called USS Hope to find out what happened to her, and then her parents arrived at our hospital,? said Pearlmutter. ?We called and found out the bad news. The parents came to us in search of their child, and I had to inform them [with a psychiatrist and priest] that their 4-year-old girl had died. They wanted to see pictures, and the only picture I had was one I had taken for teaching purposes. It showed some of the classic manifestations of tetanus, a disease that I had never seen or treated.

?Little did I know that would be the last picture these parents would see of their daughter,? said Pearlmutter. ?The parents were extraordinarily grateful for what we did. They hugged us and thanked us profusely as they walked off the compound to make their way back to Port-au-Prince.?

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Greg Thompson is a contributing writer for Axis Imaging News.