Report of IMANA Relief Haiti Team 3

1. IMANA Team 3: HAITI EMERGENCY MEDICAL RELIEF Jan 30 th – Feb 6 th – week 2 after earthquake.

2. Between 150 to 250 thousand killed Multiples more wounded and or displaced

3. Emergency Medical Disaster Relief 101: 1. Morbidity / Mortality Patterns: Acute Second wave (weeks to months to ??) - worsening / deterioration of primary insult - exacerbation of chronic conditions - lack of access to health / nutritional maintenance

4. * implications for scope of service / facility * underlies importance of communications / transport service

5. * no form of care delivery is trivial

6. The Squad: Leader – Dr. Labib Syed MD (MPH / Attending Interventional Radiology) - Dr Faiz Khan MD (Emergency/Internal Medicine) – Director of Clinical Ops - Dr. Tushar Kapoor (Emergency Medicine) - Dr. M Azhar Ali (Plastics/Reconstructive Surgery) - Dr. Alfredo Edgardo (Pediatrics) - Dr. Faiz Hussain (Internal Medicine) - Dr. Aziza Alam (Pediatrics) - Dr. Javaad Zafar (Interventional Radiology) - Dr. Syed Akhtar (Pediatric Urology) - Esther Cabeche RN (Haitian American – Telemetry / Emergency) - Janet Jasper RN (Emergency) - Ronald Tomo – Disaster/Wartime Communications Technician - Vincent Tomo – Assistant Communications Tech - Michael Greene – Tactical / Logistical Support

7. The Nassau University Medical Center gang: Dr. Faiz Khan MD – Vice Chair/Head Academic Affairs – Emergency Medicine

8. Dr. Tushar Kapoor – Emergency Medicine Director: Pre-Hospital and Disaster management The Nassau University Medical Center gang:

9. Esther Cabeche – RN Former Ms. Haiti / USA The Nassau University Medical Center gang:

10. Ronald Tomo: Chief Information Officer – VP – Nassau Health Care Corp Chief of Communications The Nassau University Medical Center gang:

11. Vincent Tomo: Former Marine - Assistant to Communications Chief - Tactical / Logistics The Nassau University Medical Center gang:

12. At start up phase: Transcend boundaries – necessary Transcend Skill Sets - necessary The pedes volume was enough that pedes could maintain their own niche.

14. As ER physicians: Roughly 800 lbs of supplies… airway equipment headlamps 2 nebulizer machines glucometer propane burner walkie talkies

15. Normal Saline: 250 cc bags X 20 500 cc bags X 30 Saline for Irrigation – 10 bottles Bacitracin/triple Antibiotic ointment – 2 boxes Unasyn 3.0 grams IV Bags - 30 Ancef 1.0 gram IV bags – 50 Lidocaine 2% - 40 bottles Toradol: 20 vials Solu-medrol: 20 vials Liquid Motrin: 20 bottles Compazine: 10 vials ? Reglan: 10 vials Pepto-Bismol/Kao-Pectate: 20 bottles Keflex 500 mg tabs: 400 Doxycycline 100 mg tablets: 400 Motrin 400 mg: 400 Tylenol Suppositories – 500 mg or largest dosage available – 100 Flagyl – 500 mg bag – X 50 Flagyl – 500 mg tabs (500 tablets) Rocephin 1 g bag – X 50 Insulin 25 vials Epinephrine vials Baby Formula powder packets or cans 50 packets or 5 cans Tetanus vaccines: 50 20 vials of Benadryl Benadryl tablets – 50 mg - 200 1 box of albuterol ampules 1 box of atrovent ampules Etomidate - 2mg/cc – 10 cc vials X 20 Versed: 10mg/2cc – 2 cc vials X 10 Morphine: 10mg/cc – 1 cc vials X 20 Ketamine 500 mg / 5 cc – 5 cc vials X 20 (NOT AVAILABLE) Propofol 10mg/1cc – 10 cc vials X 20 Fentanyl 10 micrograms / cc – 20 cc vials X 10

16. Sterile Gloves – 4 boxes size 7 Non Sterile Gloves – medium – 3 boxes Alcohol Pads – 5 boxes Bleach Wipes – 3 boxes Enfamil – 2 boxes of 48 – 2 oz 2 boxes of 48 – 6 oz Nipples – 1 case Gauze – 4 X 4 5 boxes Needles – 1 box of 50 18 gauge 2 boxes of 50 20 gauge 1 box of 50 26 gauge Angio cath – 1 box 200 – 18 gauge “ - 20 gauge “ - 22 gauge “ - 24 gauge Primary IV tubing 1 box of 100 Secondary IV tubing 1 box of 100 Peroxide – 10 bottles Betadine – 20 bottles Syringes- 1 box of 50 – 1cc 1 box of 50 6 cc 1 box of 50 12 cc 1 box of 50 60 cc (Toomy) Plaster 4 inch 100 packs Plaster 6 inch 50 packs Web Roll (under cast) 4 inch 100 packs Web Roll (under Cast) 6 inch 100 packs Ace bandage – 4 inch – 50 rolls Ace bandage – 6 inch 50 rolls Scalpel- 11 blade – 5 boxes 15 blade – 5 boxes Spinal Needle – 18 gauge – 20 Nylon – 5 boxes of 3-0 size Vicryl – 5 boxes of 3-0 size Lancets and Strips Ambu Bag – 2 adult / 2 Pedes Surgical Trays : wound X 20 / trach X 1 / thoracostomy X 1

17. Thanks Judy Eisele and NUMC EMS !!

18. Many thanks to… Art Gianelli – CEO Nassau Health Care Corporation Larry Slatky – Execitive VP / Director Of operations – Nassau Healthcare Corp. The behind the scenes heroes who approved thousands of dollars worth of supplies To be donated to the physician teams originating from Nassau University Medical Center.

19. Inventory and stocking – most neglected and just as crucial as care delivery!!!! - was a deficit for first few days !!!

20. Comprehensive Disaster Response Services: CDRS – Todd Shea www.ny times .com/2009/06/25/world/asia/25kashmir.html

21. Aimer Haiti

22. Creole Food – FRESH !!!

23. American Airlines – Dr. Faiz Hussain to the rescue…from 1100 to 450 dollars overage fee!!!

24. Santo Domingo to Port Au Prince…

25. Crossing the Border…

27. Acute Care Area pharmacy O.R Supplies/meds Admin / HQ / COMMS Resident Tents Latrenes / shower Supplies/Meds Intake / triage/ rapid care In patient Kitchen Office/supplies/meds 65% Treat/Street 3/4 Wounds/Ortho ¼ Medical 7 inpatients: (3 post-op) 35% 250 to 350 patients per day

28. Entrance Intake / Triage / Rapid Care

29. Spill over from intake Intake / triage/rapid care

30. Improve Press Gainey???

31. Dr. Aziza Alam – Pedes – up bright and early to attend to the intake area…. Dr Javaad Zafar-interventional Radiologist Re-discovering his clinical side!!! … BUT suddenly…

32. I smell an X-Ray… In a flash…

33. … and here came Dr. Zafar… unable to avoid making us clinicians feel dumb for missing “ the obvious “ on X-Ray!! Are you blind??? But it’s a limited study…suggest clinical correlation ?

34. Mobile Satellite units: We were able to deploy a team of 2 docs and supplies Into pockets of populations unable to access any facility…

35. Dr Kapoor (ER) with Suhail (NGO – actual size) Splinting an elbow injury DR. Kapoor debriding a wound

36. DR. Faiz Hussain and Dr. Syed Akhtar caring for a population pocket being fed by the Zakat Foundation of America…

37. The Acute Care Area (ACA) Mike Greene – Head of tactics and logistics…world traveler, adventurer, Humanitarian and guide. Also international man of mystery.

38. ACA

39. 70% - Wounds / Ortho : 30 % Medical conditions 2 ER physicians / Surgeon

40. IV hydration/medications/IM analgesia Debridement +/- conscious sedation Splinting / orthopedic management Respiratory treatments I/D’s Diabetes and hypertension management and education Stabilization of critical care Screening for potential OR cases OB/GYN care Abdominal Pain

41. Dr. Alam signing out an infant With moderate respiratory Distress to Dr. Khan. Baby did well after serial nebulizations– all kids responded great to interventions Thanks to Istifa Naqvi For donations of medicine and supplies!!

42. Resp. Distress on the rise

43. Toradol + Sling

44. X- Rays courtesy of the Brazilians!!

45. Janet Jasper RN cannulating a young lady with fever + dehydration Almost a smile??

46. Dr. Kapoor debriding after giving some versed and morphine….

47. Dr. Khan and RN Ester Cabeche preparing For an incision and drainage of a deep Ante-cubital abscess under IV sedation.

48. A little IV insulin and fluids for an Uncontrolled diabetic…d/c’d on Metformin.

49. Michael Greene – chief of logistics and tactical support And Ester Cabeche – RN get IV access and watch over a pedestrian struck…

51. The swollen ankle….w/ fever - To the operating room!! Where the heck are the radiologists when you need them??

52. THE O.R.

53. Dr Zafar closing the incision after ankle exploration…Ron Tomo assisting.

54. Dr Parvez Malik and Dr Azhar Ali (Plastic Surgeons) repair a hernia…

55. As dr kapoor (ER) maintains Deep sedation.

56. A girls ex-fix rods were dislodged…an orthopedist was on site that day – dr kapoor Maintained deep sedation while the orthopedist re-secured the device.

57. Dr Ali (plastics) and Dr Syed Akhtar (Urology) go to work on a skin graft. Dr. Faiz Hussain (internal medicine) assists Dr Akhtar, and Dr. Faiz Khan provides the deep sedation with Aimer Haiti volunteer Josephine calming the patient. Graft looking great, patient awake…Dr Ali and Dr. Khan after a job well done - Praise God.

58. A patient with lethargy and burns admitted…night rounds revealed deterioration: Dr. Khan and Ester Cabeche RN Re-assessing inpatient

59. Patient septic with 15 % burns… Abx and crystalloid given, central line placed by Dr. Faiz Khan. Dr. Kapoor Debrides after dose of etomidate

60. Wounds cleaned, patient more Alert…good urine output

61. Arm further debrided By Dr. Ali next morning; However patient Remained febrile. Patient Needed transfer

62. Thanks to COMMS – we got her to the USS comfort…great team effort!!!

63. Transfer capability saves LIVES…know your scope and when to call for help.

64. Transferred and secured definitive care thanks to COMMS: Meningo-encephalitis – R/O 2 acute abdomens Septic Burn OB cases/complaints Missed Ab Retained Products Spine Fractures Ultra-sound reveals intra-uterine demise.

65. A doozy of a case : 42 y.o altered mental status/lethargy, kussmauls respirations. 102.5 165/80 120 16 95% FS – 114. Exam not suggestive of ETOH / Anemia or hemolysis / no obvious source of infection. 2 Liters of crystalloid – patient more alert And now severely agitated - danger to self and others; Propofol and versed used to Get a half-hour of calm… Marine unit across the road unable to secure room on USS comfort…

66. Ron Tomo finds an ICU bed and team at nearby community hospital being run by MD team from Utah!!

67. Patient requires deeper sedation…taken to OR for optimal management of airway. 2 IV’s, Rocephin, Vanco, bicarb…set up for Rapid Sequence Induction. Positioning is EVERYTHING, as dr. kapoor draws up The etomidate and sux… Please please please Allah…don’t let it be anterior

68. After some transient laryngospasm – ETT passed….

69. Do NOT let go of the tube dr. kapoor!! Loaded in the back of the pick-up truck…Dr. Khan ventilating patient / Dr. Kapoor ready with the pavulon, etomidate, and propofol prn for the trip…

70. The sun has set…we reached the Receiving hospital… Lights and sirens through PAP

71. Patient handed off to a team from Utah…vitals stable, O2 sats 96%...requested Patient get acyclovir…and stat labs.

72. That night – guests of the Pakistani MINUSTAH mission

74. We lived, slept, ate, hungered, laughed..and cried….together

76. We fostered bonds of friendship… We matured as physicians, logisticians…and human beings

79. But we did not bask in illusions…

80. We prayed to God for the humility to serve…for the strength to sacrifice… For the wisdom to respect each other and work as a team…

81. Differing faith traditions…united to Serve God…

82. … by Serving our fellow human beings

83. And we prayed and continue to pray for the Haitian people…

84. We asked God to empower our efforts to relieve pain and suffering...for there is no efficacy or empowerment save through Divine Grace…We are nothing unless God Allows and Supports May God find us worthy to do good…may he accept our efforts…

85. Whatever small and meager efforts we made, and circumstances we endured are nothing…

86. Compared to the fortitude, struggle, suffering, endurance, and effort of the Haitian victims…

87. … may their resolve and struggle be a source and road to eventual Divine Proximity and Eternal Comfort…

88. … at the moment when we are all gathered together before our Lord.

89. God Bless the victims of Haiti’s Earthquake…