Some of the pillars of sound medical practice have to fall by the wayside when doctors and nurses treat desperate victims of mass catastrophes at a field hospital set up in the middle of hell. None of the sick or wounded is asked for his informed consent; providing privacy is an undreamed-of luxury; patients may be chosen according to who can be discharged soonest; cesarean sections are avoided if possible; and highly complex treatments are not given to victims who haven’t a chance of survival outside.
But other features of normal hospital procedures were used by members of the Israel Defense Forces team that flew to Haiti less than 24 hours after the horrific earthquake that shook Port-au-Prince six weeks ago. The doctors appointed an ethics committee to decide which victims should be admitted and which had a reasonable chance of survival. At least one of the staffers served as a medical clown to make patients smile in lieu of speaking their language. And each patient was discharged – usually to the street – with a CD containing his personal medical file, including x-rays and scans, for use in the event that he received professional follow-up later in the poorest country in the Americas.
The Israeli facility, set up as neatly arranged tents in a soccer field in the capital’s center and opened within hours of arrival, was staffed by a 121-member team with 40 doctors, 20 nurses, 20 paramedics and medics, 20 lab and X-ray technicians and administrators. Three of the physicians and one of the nurses who served there were staffers of Jerusalem’s Shaare Zedek Medical Center, while another worked with a separate nonprofit group in the disaster area. They thus constituted the largest delegation from any single Israeli hospital.
Two weeks ago, some 300 Shaare Zedek staffers crowded into the medical center’s Steinberg auditorium at 8 a.m. to attend an in-house clinical conference presented by the five who had returned from Haiti, armed with objective medical reports and emotional commentary and photos.
Dr. Ofer Merin, a senior trauma surgeon, was one of the hospital personnel who returned after about two weeks in the steamy, devastated country. Merin served as chief surgeon and was in charge of intensive care at the IDF field hospital, which was split into surgical and internal medicine branches.
“We had a blood bank, an x-ray facility that took over 200 images a day, a large amount of medications and medical equipment and 10 laptop computers. The mobile PCs were used to photograph each admitted patient and store their medical records and produce the CDs,” he said.
“As nobody in Haiti has identity cards, the photos were used to keep track of patients and for loved ones to identify them,” said Merin. “A total of 1,111 wounded and sick were treated, and 315 operations were performed. Sixteen babies, including a set of twins and a boy given by his mother the name Israel, were delivered.
“How do you choose whom to admit under such conditions, with people around you dying by the thousands? How do you decide who gets treatment when you can choose only some? Do you pick those that are in the most danger or those that have the best chance of surviving? If you have no dialysis machine for a patient you have discovered has kidney failure, what do you do?” Merin asked rhetorically.
“Only 13 people treated in the tent hospital died during the two-week stay. That means either that triage filtered out the more serious cases, or that we had performed very skillfully or both. Do you resuscitate people who need long intensive care and would be treated at the expense of others? We were prepared to give urgent care and release patients as fast as we could so we could save more,” Merin said.
He noted that in one way, being unable to communicate with patients in their native tongue made it easier because they had only to give medical care without consent and consultation; but at the same time, this took an emotional toll.
He described some of the more memorable cases: A 16-year-old boy who was severely injured when a wall fell on his chest was resuscitated, but he eventually died of systems failure. A 25-year-old woman who had been buried in rubble for five days was released in good condition a week later. A 22-year-old woman who was trapped for six days and reached the hospital with gangrene in her back and legs was treated in desperation, but she died. A young man had a bullet in his chest, apparently caught in the crossfire that resulted from looting; he received a blood transfusion and spent two hours in intensive care – and was discharged the next day.
Gali Weiss, the hospital’s chief nurse, who was selected by the IDF to fill the same position in the field hospital, said she’d had logistics experience from her IDF service doing drills of preparing Israeli hospitals for coping with disasters, but she had not gone abroad for such a purpose because of her commitment to her own children. Yet she had agreed to fly to Haiti and not only coordinate all nursing services, but also be responsible for organizing the tons of medical equipment.
“It was an incredible experience,” she told her Shaare Zedek colleagues after describing Haiti in a few factual sentences.
“The annual per capita income is $380, making it one of the poorest places in the world. Twenty-five Jews reside in the capital,” she said, including the daughter of the late Israeli peace activist Abie Nathan, and her mulatto daughter.
She and Merin stood all day and part of the night in front of the entrance of the fenced-off and well-guarded admissions tent to perform triage among those who came for medical care.
“Most of them arrived by themselves,” she said, “but some were brought to the hospital in wheelbarrows and other means of transport. Most of the nurses were young; I was the oldest among them. Since I worried how they would react to the horrors they saw, I sat down with them to talk at the end of each round of duty – officially 12 hours on and 12 hours off, but usually longer on duty. With absolute chaos all around us, the hospital was like an island of intensive lifesaving.”
Weiss added that among the children were many orphans. She became very attached to one boy whom she seriously considered for adoption.
“There was nobody to ask and nowhere to send them except to the street,” the senior nurse recalled.
The nurses and other paramedical staff worked hard to sterilize equipment in electric autoclaves immediately after use for the next operation. They were careful, she said, about documenting medical procedures, dealing with pain and preventing infection.
Because physical trauma to the limbs is common when buildings collapse in an earthquake, seven orthopedists were included in the IDF delegation. One of them, Dr. Ehud Lebel, said that computerized x-rays for follow-up could not be performed to allow more patients to be handled, even though these are always performed in Israel to determine the results of treatment.
“But to our surprise, we found we could manage without them,” he said.
Bone fractures would conventionally have been treated by opening up the limbs and inserting screws and metal plates for surgical repair, but in Haiti they were left closed, with metal pins inserted from the outside to set the bones. This technique is used only for temporary setting, but there was no choice except to use it until recovery. And without surgical drills on hand, orthopedic surgeons used ordinary do-it-yourself electric drills to make holes in bones, sterilizing the bits and covering the rest with plastic bags between operations, Lebel recalled.
“We had to compromise on equipment, even gloves,” he conceded. “There just wasn’t enough, even surgical tables.”
But the Israeli field hospital was by far the best-organized and -equipped medical facility in Port-au-Prince and the object of great praise from around the world. Additional tables arrived when a US Navy ship came into port and donated them to the Israeli facility. But the photos shown at Shaare Zedek included several of an “intensive care unit” in which seriously ill patients lay on a stretcher covered with grey army blankets while being cooled with a portable fan.
The camp’s ethics committees deliberated about whether to amputate all gangrenous limbs. If lives were in immediate danger, the limbs were amputated, the orthopedist said, but if two legs were rotting, the surgeons faced the dilemma of sending a completely helpless victim into the street where follow-up was not available.
“We hoped that when we left, others would come to provide artificial limbs for amputation victims,” he said.
In fact, teams from Magen David Adom, Herzog Hospital and Jerusalem’s Alyn Children’s Orthopedic Rehabilitation Hospital were subsequently sent, among others from abroad, to help amputees.
Lebel said that when staffers were off duty, they really weren’t “off”; there was nowhere to relax.
“We tried to close the hospital at night, but had to keep it open for urgent cases. Operating teams worked hard, often without any sleep. It was very hot and humid, and we were exhausted as equipment ran out,” he recalled.
However, Lebel was very proud of what the IDF team had done: “We saved many lives. We stabilized the conditions of people who received more treatment later. We also made some mistakes, but we helped all kinds of people.”
Dr. Doron Goldberg, an obstetrician/gynecologist, said that as he had been involved solely in delivering babies in the field hospital, his work had been joyful and involved in life, not fighting death.
“We three doctors had only one delivery room, but it had ultrasound, a monitor, a vacuum device, drugs and sterile delivery kits,” Goldberg said. One woman who thought she had only one fetus gave birth to twins. There were six cesarean sections, even though that was not the preferred means of delivery under camp conditions.
“We didn’t have their medical histories. One baby was born at 900 grams, but we decided not to resuscitate, as there was no way it could have been kept alive. We didn’t induce labor, and we couldn’t handle serious complications. We acted according to our consciences,” he said.
At one point, so many infants were born at the same time that there were no beds for them. One newborn was kept in a big plastic bowl that had previously been used to serve salad.
Prof. Eli Schwartz, who runs tropical disease clinics at both Sheba Medical Center at Tel Hashomer and Shaare Zedek, described his Haiti experiences, even though he did not serve in the field hospital but with NATAN, the Israeli Coalition for Disaster Relief named in memory of Abie Nathan.
“No other country in the world could send medical relief so quickly,” he said. “We will have to learn lessons from this experience and prepare, but it is clear that at the next catastrophe, we will again be the first there.”
He was the only doctor among a group of Israeli social workers sent by NATAN to the Haitian capital.
“At first, I couldn’t understand why social workers were needed where there were such acute medical needs. But quickly I realized it was the right thing to do. There was so much emotional trauma. We got in touch with Abie Nathan’s daughter Sharona, who speaks the language and could translate,” he said.
The Israelis established a school for children, mostly orphans, who learned amid the rubble.
“We didn’t see people in mourning. They didn’t cry. Instead they sang Catholic hymns for hours on end to cope, declaring that the earthquake came because they had sinned and had to repent,” said Schwartz.
When one verse from Psalms was translated for him, Schwartz felt electricity run down his spine. It was Psalms 51:15-18:Lord, open my lips.My mouth shall declare Your praise. For You don’t delight in sacrifice, or else I would give it.You have no pleasure in burnt offering. The sacrifices of God are a broken spirit.A broken and contrite heart, O God, You will not despise. Do well in Your good pleasure to Zion.Build the walls of Jerusalem.