Abstract:On January 12, 2010, a routine trip toHaiti for a pediatric tropical medicineelective with pediatric residentsturned into a disaster responsemission. I was accompanied by 6pediatric residents and 1 nurse, andwe were among the first nonmilitaryphysicians to enter Haiti after theearthquake. This article describesour experience upon arriving in Port-au-Prince, 80 hours after the earth-quake. This experience solidified mybelief that “children are not littleadults” and that the needs of chil-dren in a disaster are different thanthose of adults. The presence ofpediatricians in a disaster is vital tothe survival of the children.

Keywords:disaster relief; pediatrics; Haiti

Division of Pediatric Emergency Medicine,Johns Hopkins University, Baltimore, MD.Reprint requests and correspondence:Karen Schneider, MD, MPH, Division ofPediatric Emergency Medicine, JohnsHopkins University, CMSC 144, 600 N.Wolfe St., Baltimore, MD 21287.kschneid@jhmi.edu

1522-8401/$ - see front matter© 2012 Elsevier Inc. All rights reserved.

6 VOL. 13, NO. 1 • INTERNATIONAL DISASTER RELIE

InternationalDisaster Relief:

The HaitiExperience

F: THE HAITI EXPERIENCE / SCHNE

Karen Schneider, MD, MPH

n Tuesday, January 11, 2010, I had just finished a dayshift and was walking to the car. My mind was already Oon the next day. I was taking a team of 10 to Haiti:7 pediatric residents, a nurse, and a helper. At my

university teaching hospital, I had developed a pediatric tropicalmedicine elective for the pediatric and emergency medicineresidents. The course offered 4 trips a year, 1 each to Peru,Guyana, Kenya, and Haiti. Teams of residents, nurses, otherpediatric specialists, and the occasional nonmedical helpertraveled with me. We were the pediatric specialists in remoteareas where there was either no pediatrician or the people weretoo poor to have access to them. We returned to the same clinicalsites year after year and had thus built a relationship with thein-country partners. We cared for children during the day, andthe residents received a lecture in the evening on a clinicaltopic they had seen that day: typhoid, malaria, ascarias, dengue,Taenia saginata/solium, and others. I had been traveling to Haitifor 15 years, and I was excited to reunite with some of my oldfriends who helped with our work.

Our flight to Miami was the next day at 6 AM. From there, wewould fly to Port-au-Prince (PAP) by noon. I was thinking that Ishould text my contact at PAP once again to make sure he had thecorrect time to pick us up at the airport when, all of a sudden, Ireceived a text message from one of the traveling pediatricresidents, “There was an earthquake in Haiti.” Before I had achance to respond, another text came, “There are tsunamiwarnings.” I flippantly responded, “Well I told you to bring abathing suit.” I was still walking to the garage when the textmessages barraged my phone, “Earthquake in PAP!” “Earthquakein Haiti 7.0!” “Where are you? Are you alive?” I knew then thatthis was serious. I rushed home, turned on CNN, and could not

IDER

INTERNATIONAL DISASTER RELIEF: THE HAITI EXPERIENCE / SCHNEIDER • VOL. 13, NO. 1 7

believe what I saw. I, like many in the United Stateswith family and friends in Haiti, tried desperately toget in touch with people I knew in Haiti, but to noavail. Needless to say, we did not fly out the nextmorning. Instead, I met with the pediatric residentswho were supposed to go to Haiti.

“Dr. Schneider if you go…

we go!” was a reply one of

them made.

“They need us!” another

responded.

I had informed them that I had the time off and Ineeded to go and that they could now have a readingelective, to learn about tropical diseases. I neverdreamed that 6 of them would want to accompanyme. We talked about the risks of being in a disasterarea: limited food, water, poor communication,and security risks. They were not deterred. So weprepared for an entirely different trip than whatwe had initially envisioned. What was once atropical medicine elective was now a disasterresponse mission. We bought water, power bars,peanut butter and crackers, and thin sleeping mats.We already had head lights and baby wipes. Wedumped the vitamins, albendazole, antifungalcreams, and permethrin that we had planned tobring and loaded up on gauze, bandages, intrave-nous (IV) catheters, tubing and fluids, sutures,instruments, splinting materials, antibiotics, seda-tives, narcotics, and ketamine. We convincedAmerican Airlines to fly us as far as Miami, andthere we sat for 36 hours. The airport in PAP wasclosed on Wednesday and was open only to militaryaircraft on Thursday. Through Haitian-Americancontacts, we flew on a private jet into PAP on Fridaynight. It was 80 hours postearthquake when wearrived, and we were some of the first nonmilitarypersonnel to arrive in PAP. We were alreadyexhausted from the 3 days of effort of trying toget there.

We were directed to 2 large tents on the UnitedNations grounds that were within the boundary ofthe airport, enclosed by a gate that surrounded a

large field. United Nations personnel with machineguns guarded the entrance. The tents were alreadyfilled with patients on cots, some with clothes, somepartially naked. The first patient I glimpsed was awoman with a compound fracture of the femur; shewas moaning. I asked a nurse if she had received anypain medication. The response was, “Just Tylenol,we don’t have any of the good stuff.” I then beganto share my bin of medications. In addition tobeing a pediatric emergency medicine physician,I am also a Sister of Mercy (a catholic nun) andthus have connections at the multitude of MercyHospitals in the United States. Mercy Hospital inBaltimore was extremely generous. When our tripchanged to a disaster response, I contacted themand they graciously emptied their pharmacy of allunnecessary narcotics, pain relievers, and seda-tives. The few nurses began to give out narcoticmedication to the most severely injured patients.For some, it was the first pain relief they hadhad since the earthquake. We immediately becamevery popular.

For the 7 of us, the number of patients wasoverwhelming. We could not care for all of them, sowe made a decision. We were the pediatricians; wewould only care for children 16 years and younger.We split up, searched for the children and gathereddata: name, age, presence of parent or unaccompa-nied, and the nature of each injury. Within 6 hours,we had located approximately 60 children andconducted an initial assessment. Now it was time tobegin rounding on each child. We carried around abin of supplies and “attacked” each child by makinga “chart” on a scrap of paper, starting an IV if needed,cleaning and dressing a wound, making splints, andadministering pain meds and antibiotics. After a fewminutes, we would move on to the next child.Approximately 36 hours after arrival, every childhad been evaluated. Most had been treated appro-priately, but we did come upon 3 serious life-threatening errors.

1. The first was a 3-week-old breast-fed babywhose mother had died and the family hadno formula. The baby was brought to thetents approximately 36 hours before ourarrival. The baby had an IV, and D5W (nosaline) was infusing by drip!Of a 1 L bag, the 3-kg baby had alreadyreceived 800 mL. Fortunately, the baby'sfather was there to tell us that this was thefirst and only bag of fluid that had been hung.Maintenance fluid for a 3-kg infant is 12mL/h.Thus, in approximately 36 hours, the babyshould have received only 432mL of IV fluids.

8 VOL. 13, NO. 1 • INTERNATIONAL DISASTER RELIEF: THE HAITI EXPERIENCE / SCHNEIDER

Wewere not sure if this mistake was from lackof knowledge of the management of fluids inan infant or the initial provider's inexperiencewith calculating an infusion rate with just IVtubing and without using an IV pump. Therewas a generator that provided light, but therewere no outlets and no IV pumps. The babyhad IV tubing with a macro drip buretrol. In amacro drip buretrol system, 20 gtts (drops) isequal to 1 mL. This baby, therefore, needed240 gtts/h or 4 gtts/min. We were surprisedthat the baby was not seizing from hypona-tremia and there was no way to check a serumsodium. We immediately stopped the infu-sion, gave 4mL/kg of isotonic sodium chloridesolution twice, and then, because it was notavailable, we made our own bag of D10 0.25normal saline solution for the baby. The nextday, the father would have to walk to theoutskirts of the city carrying the baby, but hehad secured a ride to the north of Haiti inhopes of finding a family member whowould breast feed the baby. We triple tapedand reinforced the infant's IV and hopedthe IV would survive the walk and the6-hour journey.

2. The second child whose life was in jeopardywas a 3-year old (10-12 kg) who had receivedtwo 1-g doses of vancomycin timed every8 hours. The recommended dose of vanco-mycin for a child is 40 mg/kg per day dividedevery 6 to 8 hours. This child should havereceived approximately 120 mg every 6hours or 160 mg every 8 hours, not 1000mg every 8 hours.

3. The third seriously endangered child was athin 10-year-old boy who was traumatizedand combative and needed debridement anda dressing changed on his hand. He had atraumatic amputation of his fifth digit andmetacarpal and partial amputations of otherfingers. He was not cooperative, and conse-quently, had been sedated with 4 mg ofDilaudid. One of the pediatric residents, whojust happened to walk by, noticed that thechild was turning blue. The physicians wereconcentrating on the hand and not the airway.The resident began mouth to mouth until anambu bag was obtained. This child requiredbagging, stimulation, and one-on-one moni-toring for 12 hours. Neither Naloxone, oxygen,intubation, nor a ventilator was available.Whenever the child slept, he obstructed hisairway. The placement of an oral airway or

nasal trumpet helped with the obstruction,but if allowed to sleep, he became apneic.

Once again, we proved the adage,

“Children are not little adults!”

Because I was the only fully qualified pediatri-cian on site, I became the pediatric chief. At thechiefs' meeting that evening, I declared all childrenoff limits to anyone except a pediatrician. No onewas to administer any fluid, any pain medications,or any antibiotics. The pediatricians would do itall. Other physicians and health care personnelwere allowed to smile at the children and hand outcoloring books. I think they all were relieved. Webegan wearing badges that designated each of us as“pediatrician,” and the other specialists identifiedthemselves similarly. As people came and went, itbecame much easier to identify the capabilities ofthe volunteers.

Our first shift was 36 hours long. Therewas no foodprovided, so we occasionally pulled out the peanutbutter and power bars. We thought we were smart inbuying cases of bottled water in Miami. In a disaster,the Federal Emergency Management Agency recom-mends a 3-day supply of one half to 1 gallon ofdrinking water per day.1 We arrived at the airportwith a small bag of clothes, a sleeping mat, largeplastic bins of supplies, and 1 case of water for each ofus only to be told that the water was too heavy and itcould not be put on the small plane. When they werenot looking, we stuffed our bags, bins, and clotheswith bottles of water. In all, we probably broughtdown only 2 cases of water, each of us carrying 5 to6 bottles of 12 oz of water. That was all the water wehad for 4 days. Occasionally, a 5-gallon jug of waterwould arrive at the site, but there were 250 patientsand 50 volunteers. It was gone in minutes, with theonly evidence being an empty bottle.

Most of the children had crush injuries. Haiti is acountry that had been stripped of wood, first by thecolonists and then by their own people using woodand charcoal to cook. In the 15 years that I hadbeen traveling to Haiti, I had watched the mountainsides become stripped. What was once lush greenwas now brown. For this reason, a good rainstorm orhurricane would create a flood in the valley beneath

INTERNATIONAL DISASTER RELIEF: THE HAITI EXPERIENCE / SCHNEIDER • VOL. 13, NO. 1 9

the mountains; another type of natural disaster thatplagues Haiti. Fertile top soil has washed away,leaving the mountains barren for years upon years.So, to cook food, the mountains were left bare oftrees, and houses, including their roofs, were builtwith cement. Thicker rebar (steel rods) is expensive,so most middle to low income houses were built witha thinner rebar. This is enough to support the roofbut not enough to withstand a 7.0 earthquake. As theground shook, the roofs collapsed, and blocks ofcement fell on the inhabitants.

Crush injuries affect more than the body partcrushed. We arrived 80 hours postinjury, too late toperform a fasciotomy on closed, swollen extremities,and besides, if we had performed some fasciotomies,how would we keep the wound clean? We had alimited supply of sterile gauze for dressings, fewsterile gloves, and no sterile drapes. It was too risky,and we had arrived too late. We worried aboutmyoglobinemia and renal function. We gathered afew empty water bottles and began monitoring thecolor of the children's urine. Most of the childrenwere so severely injured that they were cot boundand not roaming around. Thankfully, “pee pee” is auniversal term and I taught the pediatric residentsthe other creole expression “mewn bezoin fe peepee,” “I need to make pee.” We did not have theluxury of renal function tests. We only had our eyesto assess the transformation of the urine from yellowto that dreaded dark tea color. All of the urine was adark yellow. All the children were dehydrated andthirsty. Once the tea color appeared, we beganmeasuring urine output, estimating the amount in a12-oz water bottle. The boys were easy; they couldurinate directly into the bottle. It was sometimes achallenge and took 3 of us to collect the girls' urine,especially from the girls with multiple fractures oftheir lower extremities. We grabbed any largecontainer/bucket that we could find. Initially, itwas a thick cardboard box, and we placed it underthe girl. These were the days before the Foleycatheters had arrived. More IV fluids were arrivingbut still not a sufficient amount for all the patients,and as the urine changed color, we prioritized thesechildren to receive the IV fluids first. There still wasvery limited drinking water. We pumped in the fluidin hopes of washing away the myoglobin until wenoticed the urine output dropping. The kidneys wereshutting down. We then moved these children to thetop of the evacuation list and begged to get them outof the country.

Charles was 12 years old and had severe crushinjuries to his bilateral lower extremities. He was theonly survivor of his mother's 4 children. We watchedhis legs “blow up,” and as they got bigger, we were

no longer able to palpate peripheral pulses becausehe was so swollen. We helplessly watched him losesensation below the knees in both legs. His legsbecame cold, and the skin blistered and beganweeping. By the fifth day postearthquake, hedeveloped a fever. That night, he began to experi-ence rigors, his urine changed color from yellow totea color, and his output was precipitously droppingto nothing. To save his life, we thought we needed toamputate both legs. There was a graver problem.Although the surgeons and anesthesiologist hadarrived, we knew this boy would not survive adouble amputation in our primitive setting, usingketamine sedation on an office table. He needed areal operating room and intensive care unit supportin a full-service hospital.

We talked with the physicians running the showand explained the situation. They thought he was toofar gone and did not approve his transportation toMiami. “We have a limited number of people we cansend and we want to make good use of the trans-ports,” I was told. In other words, they were going tolet him die. Delphine, the pediatric resident who wasprimarily caring for him, was distraught. It was thewee hours of the morning. I was furious andstepped outside the tent to cool off and take awalk. I ran right into a man who had a truckload ofdonations that he was bringing to the tents. Hestarted asking questions and I returned some of myown. He was wealthy, had his own plane, had justlanded, and was bringing water, food, clothes, andmedical supplies. He saw the tears in my eyes andlistened as I told him about Charles. He hadplanned to stay for a few hours but “yes,” he wouldtake Charles immediately to Miami without papers,without permission, and without hospital accep-tance. He knew this might cause trouble for himupon returning to the United States, but he waswilling to take the risk. We unloaded the truck andwithin 30 minutes, Charles on his stretcher wasloaded onto the truck. We did not think it was agood idea to send the mother; a lone sick childwould be received much better, and besides,Charles' father lived in Miami. The next day, themother stopped by the tents to say that Charles'father had called her; Charles was in the hospital.She came back to the tents with gratitude to giveus the good news. Here was a woman who, in thepast 5 days, had experienced the death of 3 of herchildren and sent the fourth and only remainingchild to the United States knowing she might neversee him again, and that he too might die withouther, and she was thanking us!

There are so many children who will stay in mymind, and 2 years later, I can still recall their names.

10 VOL. 13, NO. 1 • INTERNATIONAL DISASTER RELIEF: THE HAITI EXPERIENCE / SCHNEIDER

Jolette, a 14-year old, was returning home fromschool and was almost at the entrance of her housewhen the earth shook. She saw her house collapse,crawled into it twice, and dragged out her uncon-scious mother and infant sister. Then, when a wallof the neighbor's house collapsed, a big block ofcement fell on the upper part of her body, pinningher to the ground. Besides a shoulder injury, with aprobable fracture, she sustained a LeFort 3 fracture,her whole midface was mobile. She desperatelyneeded to go to the United States.

Katie, a 12-year old, had just arrived home fromschool and was the only surviving person of the 6who lived in her house. Obvious to the eye werebilateral femur fractures and right humerus, ulna, andradius fractures. Her first words to me when I mether were, “What is going to happen tome?Mymotheris dead, my father is dead and my body is broken.”

Jean, affectionately known as “Pushant,” sus-tained a devastating injury to his left lower leg.Something had sheared off one-third circumferenceof the skin andmuscle from knee to ankle exposing amultifractured tibia. On my first day, day 4postearthquake, I gave him some ketamine andwashed it out. On day 5, while again washing it outand trying to align the bone, I noticed that one of thepieces that I thought was bone was actually a rock soI removed it. On day 6, he developed a fever andrigors, dark urine, and decreased urine output. Theleg stank. We had already been treating him withantibiotics for 2 days. The infection was gettingahead of us. There was no way we would be able toclose this wound in this tent. He was getting sicker.He would need an amputation to save his life. Hecried because he had wanted to be a doctor;however, people with deformities in Haiti did notgo to school. He was a serious student. “See, I canwiggle my toes,” he begged. The surgeons hadarrived, and the amputations had begun. I putPushant on the top of the list of the childrenrequiring surgery. When we gave him the option ofan amputation or dying, he thought for a minute. Hehad witnessed his father crying when he found hismother and 2 sisters dead. He could not do that tohis father again. “Take off my leg, my father needsme.” he said, “I am all he has left.”

After the first 36-hour shift, I slept 4 hours thenworked another 20 hours and slept 4 hours, and soon. There were no cots for the volunteers, wewould lie on any piece of ground that was not beingused for something else. Once I slept beneath atripod for a CNN camera, another time I placed mymat on 3 sturdy cardboard boxes that I had puttogether, and once, under a desk. By the fifth day,my mat was gone.

There was only one time when I became seriouslyangry. A new nurse had arrived and her self-proclaimed mission was to organize everything.While the environment was somewhat chaotic, wehad achieved a bit of organization and most of usknew where most things were. To the left of the tentwere IV supplies, to the right were dressingmaterials, and in the center around the tableswere the medications. You still might need to huntfor things, but they could be located in these generallocations. We pediatricians had brought 5 bins ofdisaster materials, but we also carried pediatric-specific equipment, IVs, intraosseus needles, naso-gastric tubes, oral airways, nasal trumpets, armboards, and others. We had placed large signs on thebins, “PEDIATRICS. DO NOT TOUCH!” This nursewas quite manic in her work and did not sleep ortake water or food for more than 48 hours. Sheproclaimed that she was strong. She also did notfollow direction. I had told her multiple times not totouch the pediatric bins. The day after her arrival Inoticed my bins were empty and put on the side.She must have emptied them while I was napping,creating confusion out of reasonable order. Thatmorning, we had another large aftershock, a 6.0 thatshook the ground for 20 seconds. It shook so hardthat I fell to the ground. It once again would be abusy day. We knew we would be receiving morewounded as unstable walls and houses collapsed,and indeed, we did. We had a child arrive whosemother was boiling water while the baby was at herfeet. This large aftershock knocked the boiling wateroff the stove and onto the infant, who sustained a50% body surface area burn. This baby needed painmedication and sedation for a burn debridementand IV fluids and I could not find my 24- or 22-gaugeIV catheters. The baby was too sick to want to suckand I could not find a pediatric-sized nasogastrictube to give some Pedialyte to keep her hydrated.This baby was going to die because we could nolonger locate vital supplies. I was furious! It mayhave been the first time in my life that I actuallyyelled at someone and she received a week's worthof pent up anger and frustration. We ultimatelycould do nothing for the baby. We could not place an18-gauge needle in an 8-month old's arm. Wecrushed oxycodine and placed some on her tonguein hopes that she would receive some pain relief. Iput the baby on the top of the list of children to betransported out.

When a pregnant woman at 34 weeks gestationpresented to us in labor, it was decided that wewould transfer her to the Israelis who had aneonatologist and actual incubators set up in tentsnot too far away. I volunteered to go on the transport

INTERNATIONAL DISASTER RELIEF: THE HAITI EXPERIENCE / SCHNEIDER • VOL. 13, NO. 1 11

in case the baby was born on the way. The Israelisgraciously resupplied me with pediatric supplies,which I then carried around with me all day andslept on at night. This particular nurse collapsedfrom dehydration and exhaustion later that eveningand was placed on a small jet back to the UnitedStates. I still do not regret yelling at her.

This particular mission to Haiti had its own storeof surprises. First of all, I was amazed at how manypeople dropped everything to go to Haiti to help.Second, I was amazed at how many of them showedup with practically none of the tools of their trade:surgeons without scalpels or anesthesiologists with-out pulse oximeters. I have been doing internationalwork for many years and had acquired a few toysthat I bring with me on every trip: a field hemoglobinmachine; an ultrasound Doppler; battery-operatedpulse oximeters and capnography monitors; infant,child, adult, and large adult blood pressure cuffs;glucometers; head lights; otoscopes and ophthalmo-scopes; urine pregnancy tests; urine dipsticks; andtons of batteries. The anesthesiologists quicklybecame my best friends and acquired the pulseoximeters, capnography monitor, hemoglobin ma-chine, and blood pressure cuffs.

I had told my residents that they could get on aplane and leave whenever they had had enough. Forthe 6 of them, still in training, it was their firstdisaster. I was already a veteran of 2 previousdisasters. Three of my pediatric residents left after4 days; the other 3 left on day 5; my nurse friend,

a Sister Of Mercy, stayed with me. Thankfully,a couple of new pediatricians had just arrived. I hadreceived a message that Miami Children's Hospitalwas sending clinicians. I did not feel as though Icould leave. I could not write notes on the greaterthan 100 children who were under our care so howwould anyone know what had happened to them? Itwould be much easier if I stayed and signed themout. Finally, on my ninth day, a team of 8 arrived: 5pediatricians and physician assistants and 3 nurses.The nurse-patient ratio would be 40 to 1. I was neverso happy to see anyone in my life. I was exhausted. Ittook me 12 hours to sign out the patients. I stuckaround for another 12 hours in case there were anyquestions and then we returned to the US on a coastguard evacuee transport plane. Sleep overcame me,and I do not remember takeoff or landing!

If you are wondering what happened to Charles…one of the pediatric residents found him in Miami.He was admitted to a hospital in Miami, was placedon dialysis for a short time, but then his kidneysrecovered; he did not need an amputation, and afterhospitalization, he went to a rehabilitation hospitalwhere he learned to walk with support. His legswill never be the same but he is walking!

REFERENCE1. Federal Emergency Management Agency. Prepare for a

disaster—water. Available at: http://www.fema.gov/plan/prepare/water.shtm. Accessed 9/20/2011.