SPECIAL ARTICLE

Anesthetic Practice in Haiti After the 2010 Earthquake

Mark J. Rice, MD,* Alan Gwertzman, MD, Timothy Finley, DO, and Timothy E. Morey, MD*
On January 12, 2010, a 7.0 M
L
earthquake devastated Haiti, the most impoverished nation in
the Western hemisphere with extremely limited health care resources. We traveled to Milot,
Haiti situated north of Port-au-Prince, to care for injured patients at Ho pital Sacre Coeur, an
undamaged hospital with 74 beds and 2 operating rooms. The massive influx of patients
brought by helicopter from the earthquake zone transformed the hospital to 400 beds and 6
operating rooms. As with the 2005 Kashmir and 2008 China earthquake, most victims suffered
from extremity injuries, encompassing crush injuries, lacerations, fractures, and amputations
with associated dehydration and anemia. Preoperative evaluation was limited by language
issues requiring a translator and included basic questions of fasting status, allergies, and
coexisting conditions. Goals included adequate depth of anesthesia, while avoiding
apnea/airway manipulation. These goals led to frequent use of midazolam and ketamine or
regional anesthesia. Although many medications were present under various names and
concentrations, the absence of a central gas supply proved troublesome. Postoperative care
was limited to an 8-bed postanesthesia care unit/intensive care unit caring for patients with
tetanus, diabetic ketoacidosis, pulmonary aspiration, acute renal failure due to crush, extreme
anemia, sepsis, and other illnesses. Other important aspects of this journey included the
professionalism of the health care personnel who prioritized patient care, adaptation to limited
laboratory and radiological services, and provision of living arrangements. Although chal-
lenging from many perspectives, the experience was emotionally enriching and recalls the
fundamental reasons why we selected medicine and anesthesiology as a profession. (Anesth
Analg 2010;111:14459)
O
n January 12, 2010, a 7.0 M
L
earthquake with its
epicenter in Leogane, Haiti, approximately 16
miles west of the capitol Port-au-Prince, devastated
both of these cities.
a
Twelve days later, we arrived at
Ho pital Sacre Coeur in Milot, Haiti to care for injured
patients. In the following, we offer our observations as a
guide to other anesthesiologists who may wish to travel to
Haiti or other countries after catastrophic events to provide
anesthetic care for the injured.
OVERVIEW
Haiti is on the island of Hispaniola, which encompassed a
Haitian population of approximately 10.033 million in
2009.
1
The income per capita is approximately US
$520/year (United States [US]: $46,040/year) with a large
majority of Haitians living in poverty. The average life
expectancy is 61.5 years, the lowest in the Western hemi-
sphere (US expectancy: 79.4 years).
1
The Haitian govern-
ment estimates that 200,000 people died during and
immediately after the January 12, 2010 earthquake and an
additional several hundred thousand people were injured.
b
This is similar in human devastation with the Wenchuan,
China 8.0 M
L
earthquake of 2008 that injured 370,000
people.
2
Before the island earthquake, Haitian hospitals
had approximately 1.3 beds/1000 population (US: 3.1
beds/1000).
1
Such a large instantaneous influx of severely
injured citizens would overwhelm even the most well-
resourced health care system. Clearly, Haiti needed mas-
sive health care assistance.
HO

PITAL SACRE

COEUR
We worked in Milot, a village 9 miles south of Cap Haitian
and 54 miles north of Port-au-Prince, which houses the
nations largest private hospital, Ho pital Sacre Coeur (Fig.
1). Normally, Ho pital Sacre Coeur serves a local population
of approximately 225,000 people with 74 inpatient beds and
2 fully functional operating rooms (ORs) allowing approxi-
mately 1200 operations in 2008. Surgeons and anesthesiolo-
gists from the US rotate through the hospital on a weekly
basis to perform various operations. Locally, Haitian sur-
geons reside on site for routine operations (e.g., cesarean
deliveries) with anesthesia provided by Haitian-trained
nurse anesthetists. The typical weekday operative caseload
is 5 to 7 operations/day with an emphasis on spinal
anesthesia. General anesthesia is usually considered to be
dangerous for a number of reasons including malfunctions
of the anesthesia machine ventilator, frequent hospital
generator failure, and hypoxia. Because the earthquake did
not damage Milot, this disaster transformed the hospital
into a major depot for trauma patients from affected areas.
In the chaotic days after the earthquake, 360 newly
injured patients overwhelmed the hospital. This influx
caused the hospital to become extremely disorganized.
Patients scheduled for surgery were misplaced as new
wards were opened in the adjacent schools. Patient names
on posting slips were incorrect and the use of the native
a
Romero S, Lacey M. Fierce quake devastates Haitian capital. The New York
Times, January 12, 2010.
b
Baker P, Berger J. US to resume airlift of injured Haitians. The New York
Times, January 31, 2010.
From the *Department of Anesthesiology, University of Florida, Gainesville,
Florida; and Bergen Anesthesia Associates, Holy Name Hospital, Teaneck,
New Jersey.
Accepted for publication August 11, 2010.
Study funding information is provided at the end of the article.
Disclosure: The authors report no conflicts of interest.
Reprints will not be available from the author.
Address correspondence to Timothy E. Morey, MD, Department of Anes-
thesiology, University of Florida, PO Box 100254, Gainesville, FL 32610-0254.
Address e-mail to morey@ufl.edu.
Copyright 2010 International Anesthesia Research Society
DOI: 10.1213/ANE.0b013e3181fa3241
December 2010 Volume 111 Number 6 www.anesthesia-analgesia.org 1445
Creole language contributed to miscommunication. Incom-
ing supplies from relief agencies were scattered in various
places throughout the local health care system and may
have been in adequate supply, but frontline providers did
not know this because there was no effective supply
function. The quickly recognized need for better organiza-
tion prompted a multidisciplinary team approach with the
designation of an anesthesiologist to lead the preoperative
holding, ORs, postanesthesia care unit (PACU), and grow-
ing intensive care unit (ICU). Over several days, this
organizational superstructure to the ORs and associated
areas along with the interpreters allowed more systematic,
efficient, and orderly care of surgical patients.
Given the pressing need for surgical care, 2 ORs were
inadequate and 4 additional rooms in the OR area were
converted to primitive ORs with no modern monitoring
capability (Fig. 2). In these additional rooms, not even the
standards of basic anesthesia monitoring could be met.
3
Thirty to 35 cases/day in these locations were relegated to
those that lent themselves to IV sedation and regional ane-
sthesia. Patients in these additional rooms were assessed and
monitored by traditional physical examination: chest excur-
sion, color, carotid pulse, and manual arterial blood pressure
measurement. Ten days after the earthquake, Philips Health-
care (Andover, MA) equipped, at no cost, all 6 anesthetizing
locations and the PACU with modern, fully functional moni-
tors (IntelliVue MP90 with gas modules).
PREOPERATIVE EVALUATION
Communication with patients was difficult. Creole, along
with written French, is the official language of Haiti and
spoken by all the native people. Written French appeared to
be common in most hospital documents. Almost none of the
patients and families we encountered spoke English or French.
For these reasons, an interpreter was essential to perform the
preoperative evaluation unlike the situation for anesthesiologists
in the Wenchuan, China earthquake disaster zone.
4
The medical history usually encompassed the date of
injury (always January 10, 2010, the day of the earthquake),
other previous medical problems (almost none of our
patients had ever seen a doctor), verification of fasting
status, and inquiry about drug allergies. Many patients
were dehydrated or under-resuscitated, a finding also
echoed by anesthesiologists caring for similarly injured
patients after the Wenchuan, China earthquake.
2,4
Because
Figure 1. Front of Hopital Sacre Coeur facing the
main road in Milot, Haiti on January 25, 2010.
Figure 2. Inside of an examination room that was converted to
operating room to meet the surgical demand after the earthquake.
SPECIAL ARTICLE
1446 www.anesthesia-analgesia.org ANESTHESIA & ANALGESIA
modern diagnostic tools were either not available or very
limited, physical examination skills were the usual means
for patient assessment.
Fortunately, the hospital possessed a very functional
laboratory. Common blood tests including a complete
blood count, electrolytes, creatinine, and glucose values
could be rapidly obtained during the day. In addition, there
was a small blood bank and it was supplied by local
community donations, although the resident human immu-
nodeficiency virus prevalence is estimated to be 2.0% to
3.1%.
5,6
The blood bank did not fractionate their products
so only whole blood was available. We did not observe
adverse reactions to whole blood, a finding noted by
physicians working after the Wenchuan earthquake. Point-
of-care testing was performed using handheld devices
brought by American medical staff, but disposable cas-
settes were quickly exhausted. Anemia was very common,
secondary to preexisting malnutrition and severe injuries
with concomitant blood loss. Radiology services consisted
of 1 fixed-location machine. Radiographs took approxi-
mately 2 hours to process, the capacity was 2 per hour, and
the quality was marginal. Nevertheless, these films pro-
vided adequate confirmatory evidence of many orthopedic
injuries.
INTRAOPERATIVE CARE ISSUES
Timing of Medical Care
The types of injuries and medical problems encountered
depended on the time from the disaster to the time that care
was given. As shown in Table 1, the problems that may be
seen intraoperatively differ between the acute injuries and
the more chronic problems. We arrived 2 weeks after the
earthquake and witnessed the transition from taking care of
the fractures and other injuries to what turned out to be
even more serious problems such as tetanus, diabetic
ketoacidosis, and sepsis.
Expanding a Small Rural Hospital to a
Trauma Center
When a disaster of this magnitude strikes a country, there
is a high likelihood of having to quickly transform a small
hospital into a large receiving hospital. The challenges of
this task are enormous, including:
Increasing staffing levels of physicians, nurses, aides,
and interpreters (if needed) on site;
Providing a means to communicate between triage
personnel and hospital-based providers;
Increasing the facilities and equipment needs to
handle the large influx of patients;
Procuring the large increase in supplies needed; and
Ensuring that transportation of critically ill patients is
done in the safest possible manner.
Medical Gases
H cylinders were the only source of oxygen and were
supplied by trucks from a distant location. These tanks
were attached to a flow regulator for use with anesthesia
machines, but there was no pressure gauge on any of the
tanks. Tanks were inconsistently color coded and varied in
hue: green, partially green, partially blue, brown, and
white. All were rusted and most were labeled with tape
reading plen (full) or vid (empty).
Medications
Medications frequently used in anesthetic practice were
available in the OR suite although less frequently used
drugs (e.g., flumazenil, milrinone) were not. In addition,
because the manufacturing origins of the drugs were from
many nations, the name and concentrations of the drugs
sometimes varied from those familiar to clinicians practic-
ing in the US and necessitated scrupulous attention to
labeling. Several anesthesiologists and other physicians
brought medications with them from the US, including
antibiotics, oral analgesics, narcotics, local anesthetics,
propofol, volatile anesthetics, ketamine, and midazolam.
All medications and supplies were deposited into the OR,
although oral analgesics and antibiotics were added to the
hospital pharmacy stock for ward use. Because of the
disorganization of supplies, both anesthesia and surgical
clinical providers searched for and collected supplies from
the various caches before beginning every case. We highly
recommend the presence of an anesthesia technician, which
would have provided a large measure of organization to
ensure smoother anesthetic services.
General Anesthesia
Because of the absence of anesthesia machines and venti-
lators in several of our ORs, we learned that spontaneous
respiration was essential for rapid emergence with the
opportunity to bypass the PACU, and extremely rapid
turnover of 5 to 10 minutes between cases. To achieve
these goals with the constraints placed on us, very deep
sedation was frequently employed using IV midazolam
(0.050.10 mg/kg) and ketamine (1.02.0 mg/kg) with
augmentation by locally administered anesthesia if pos-
sible. Occasionally, minimal bolus doses (0.3 mg/kg) of
propofol were necessary as a supplement for its hypnotic
effects. Similarly, Mulvey et al.
7,8
reported a heavy reliance
on benzodiazepines and ketamine when treating victims of
the 7.6 M
L
Kashmir earthquake of 2005. For more complex
cases requiring airway management, general anesthesia
was induced with propofol with maintenance by a volatile
anesthetic. For other disasters, we highly recommend a
large stock of a short-acting benzodiazepine and ketamine.
Airway Issues
Airway problems encountered included those resulting
from facial trauma and burn victims. The available airway
Table 1. Medical Problems of Acute and Chronic
Injuries Associated with Earthquakes
Acute Chronic
Amputation Infection
Lacerations Dehydration
Long bone fractures Malnutrition
Facial fractures Renal failure
Pelvic fractures Anemia
Burns Diabetic ketoacidosis
Crush injury Fulminant tetanus
Degloving injury Myoglobinemia
Anesthesia in Haiti
December 2010 Volume 111 Number 6 www.anesthesia-analgesia.org 1447
equipment was limited because general anesthesia was
infrequently performed before the earthquake in the hos-
pital. We encourage others who enter a disaster area such
as this to bring their own airway management devices with
which they are most facile as backup airway equipment.
Regional Anesthesia
Many buildings in the Port-au-Prince area were made of
unreinforced masonry, which is similar to Wenchuan.
9
Because of these structural problems, many of the injuries
were extremity fractures amenable to regional anesthesia, a
view also reinforced by anesthesiologists caring for Chinese
patients after the 2008 earthquake.
2,4
In addition, minimal
to no postoperative IV analgesics were available for pa-
tients with moderate to severe pain. To a large extent, lower
extremity procedures were ideally suited to spinal anes-
thetics. In addition, some of these patients were discharged
from the OR directly to the wards, especially as the PACU
evolved to become an ICU for the entire hospital. Although
some spinal anesthesia kits were available, the most cost-
effective and smallest logistical footprint for travel were
spinal needles and ampules of local anesthetic.
We performed infraclavicular brachial, femoral nerve,
popliteal nerve, saphenous nerve, and ankle blocks with a
nerve stimulator because no ultrasound was available.
Many patients with extremity injuries would have ben-
efited from the use of perineural sheath catheters with
continuous infusion of local anesthetic after orthopedic
surgery.
10
We did not have the requisite equipment to place
these catheters nor were the ward nurses familiar with the
postoperative care. In addition, we contemplated making
pain rounds in the evenings, but this idea failed given the
logistical and communication obstacles. Regional anesthe-
sia was extremely useful to provide operative anesthesia
and postoperative analgesia while reducing the burden on
the PACU.
POSTOPERATIVE CARE
Postoperative care was available in an 8-bed recovery
room. As with the ORs, Philips Healthcare equipped this
location with modern monitors. Auxiliary oxygen required
that an H cylinder of oxygen be placed in the PACU. Many
patients could use a single oxygen cylinder if multiple
valves were daisy-chained from the pressure regulator.
Some fatalities occurred in the PACU/ICU during our
tenure. These included individual patients with fulminant
tetanus, diabetic ketoacidosis, pulmonary aspiration, renal
failure after rhabdomyolysis, and many cases of sepsis.
There were simultaneously 3 patients with hemoglobin
concentrations 3.0 mg/dL in the ICU. One patient had a
seizure that we interpreted to be an anemic seizure, an
event none had witnessed previously and has not other-
wise been reported. The presence of a critical care medicine
physician would have been a welcome addition.
AIR EVACUATION
The primary mode of transportation for injured patients
coming from the quake area was the US Navy. The
Seahawk (the US Navy version of the US Armys Black-
hawk) helicopter made flights from the earthquake area to
our hospital numerous times a day. The local soccer field
became the focal point for initial evaluation of injured
patients. Orthopedic surgeons would assist with initial
evaluation, because the vast majority of our patients had
long bone fractures. These fractures were often open and
infected, a situation previously reported with the 2005
earthquake in Kashmir, with a 78% incidence of limb
injury.
7,8
We observed few chest or abdominal injuries
likely because such patients did not survive the interval
before we arrived. With no ability to ventilate patients
lungs long-term and extremely limited intensive care capa-
bility, we attempted to transfer patients to the only facility
capable of caring for these people, the USS Comfort. That
ship was extremely busy and the demand for care usually
exceeded its capacity. We attempted to transfer an intu-
bated child (continuously hand-ventilated because of ab-
sence of a ventilator) to the USS Comfort but the child died
during transport.
PROFESSIONALISM
Professionalism endures as a hallmark of the practice of
anesthesiology. Four specific aspects of this trait emerged
during our service in Haiti. First, compassion and sensitiv-
ity to the plight of injured Haitian patients and their
families was necessary. From the familys point of view, an
injured loved one may have been trapped under rubble in
Port-au-Prince, been evacuated to Milot by helicopter, and
admitted to a new hospital without their knowledge.
Second, the foreign medical staff was sensitive to Haitian
health care practitioners. Haitian medical staff operated the
hospital where we worked. We were visitors in their
hospital and remained cognizant of our status as guests
while concurrently providing the care. To that end, we tried
to cooperate in maintaining accurate OR logs, use proper
pharmacy and laboratory requests, and abide by other
hospital policies. Third, we needed the ability to adapt an
anesthetic plan to changes in patient status and availability
of equipment and supplies. This flexibility was evident for
anesthesia providers who repaired anesthesia machines,
reappointed oxygen cylinders for multiple patients in the
PACU/ICU, and provided emergent anesthesia in some
cases without monitors or oxygen. Finally, medical staff
met nightly to discuss daily challenges and possible solu-
tions. This feedback was important to follow-up planning
and led to immediate changes in operations.
OTHER ISSUES
Security
During our stay at Ho pital Sacre Coeur, we felt perfectly
safe. Even at night, the women in our group felt safe
enough to walk the quarter mile from the residential
compound where we lived to the hospital. However, in the
course of our week, there was a noticeable increase in the
people living in the streets; most of these people had
moved from the earthquake zone. The future security
environment is unknown and dependent on the United
Nations troops, Haitian military and police, and nongov-
ernmental organizations. Security concerns are not unique
to Haiti. After the earthquake in Wenchuan, the Chinese
government quickly moved troops into the disaster area.
11
With mounting desperation for food and shelter, it is
SPECIAL ARTICLE
1448 www.anesthesia-analgesia.org ANESTHESIA & ANALGESIA
unknown how secure these health care facilities will be in
the coming months.
Preparation and Survival
Tropical diseases are a fact of life in Haiti, but receiving the
appropriate immunizations and arranging for prophylaxis
before traveling was straightforward. If hepatitis B and
tetanus immunizations were current, additional prophy-
laxis was required for hepatitis A and typhoid. Because
malaria is common in Haiti, our group members took
doxycycline. Tuberculosis is endemic in Haiti. Although
there is no prophylaxis, we were advised to take N95
masks. Finally, with approximately 2.0% to 3.5% of the
Haitian population positive for human immunodeficiency
virus, universal precautions were necessary to avoid con-
tact with body fluids.
5,6
The most important resource in a
natural disaster such as this is water.
12
We were fortunate
that the United Nations kept us well supplied because the
local drinking water was not safe. Before entering a disaster
area, make sure your supply of water is adequate.
Communications
Electricity at the hospital was supplied by diesel genera-
tors. There are no landlines and no power grids in this area.
At the hospital, intramedical staff communications were
limited to 20 2-way radios. Cell phones worked intermit-
tently and were highly position-dependent as was the
compounds only satellite phone. Internet using a satellite
high-speed system provided 5 Ethernet stations attached to
a variety of computers. The Internet became a very impor-
tant source of information, with searches ranging from
treating an unfamiliar disease such as tetanus to determin-
ing the volume of an H cylinder.
CONTRAST WITH THE WENCHUAN EARTHQUAKE
Although the injuries we encountered were similar to those
described with the Wenchuan earthquake, there are a
number of important differences with responding to a
natural disaster in a third-world foreign country, as de-
picted in Table 2, compared with responding to a calamity
in your own country.
CONCLUSIONS
In summary, the Haitian people needed massive health
care assistance of every kind. We were fortunate to have the
opportunity to provide anesthetic care in an undamaged
hospital to a large number of extremely grateful patients
suffering from mostly orthopedic injuries. Although chal-
lenging from many perspectives, the experience was emo-
tionally enriching and recalls the fundamental reasons why
we selected medicine and anesthesiology as a profession.
We hope that others will likewise embrace this fulfilling
opportunity and serve.
STUDY FUNDING
Funding and supplies for this activity were provided by
Shands Hospital at the University of Florida (Gainesville, FL),
the CRUDEM Foundation (Lowell, MA), and unknown aircraft
owners and operators who donated time and fuel.
AUTHOR CONTRIBUTIONS
All authors helped write the manuscript and all authors
approved the final manuscript.
ACKNOWLEDGMENTS
The authors thank Nikolaus Gravenstein, MD, for editorial
comments and our colleagues whose flexible scheduling al-
lowed us to work in Haiti.
REFERENCES
1. Pan America Health Organization. Health Situation in the
Americas: Basic Indicators 2009. Washington, DC: World
Health Organization, 2009
2. Jiang J, Xu H, Liu H, Yuan H, Wang C, Ye J. Anaesthetic
management under field conditions after the 12 May 2008
earthquake in Wenchuan, China. Injury 2010;41:e13
3. ASA House of Delegates. Standards for Basic Anesthetic
Monitoring. American Society of Anesthesiologists, Park
Ridge, IL. 2005. http://www.asahq.org
4. Chen G, Lai W, Liu F, Mao Q, Tu F, Wen J, Xiao H, Zhang JC,
Zhu T, Chen B, Hu ZY, Li RM, Liang Z, Nie H, Yan H, Yang
BX, Du Q, Huang WX, Jiang YW, Kwan AS, Song L, Wu CM,
Xiang T, Xu HW, Lau WB, Song HB, Wen CB, Yao ZH, Zhang
L, Zeng J, Dai YE, Lopez BL, Zheng JQ, Zhou J, Christopher
TA, Ma XL, Yu H, Xu LL, Guo Q, Song ZP, Volinn E, Kryger K,
Cao Y, Ge H, Liu H, Luo CZ, Tao W, Zuo YX, Liu J. The dragon
strikes: lessons from the Wenchuan earthquake. Anesth Analg
2010;110:90815
5. Halperin DT, de Moya EA, Perez-Then E, Pappas G, Garcia
Calleja JM. Understanding the HIV epidemic in the Dominican
Republic: a prevention success story in the Caribbean? J Acquir
Immune Defic Syndr 2009;51:S529
6. Figueroa JP. The HIV epidemic in the Caribbean: meeting the
challenges of achieving universal access to prevention, treat-
ment and care. West Indian Med J 2008;57:195203
7. Mulvey JM, Qadri AA, Maqsood MA. Earthquake injuries and
the use of ketamine for surgical procedures: the Kashmir
experience. Anaesth Intensive Care 2006;34:48994
8. Mulvey JM, Awan SU, Qadri AA, Maqsood MA. Profile of
injuries arising from the 2005 Kashmir earthquake: the first
72 h. Injury 2008;39:55460
9. Hudnut KW. ShakeOut, California style. Anesth Analg
2010;110:6556
10. Ilfeld BM, Morey TE, Enneking FK. Continuous infraclavicular
perineural infusion with clonidine and ropivacaine compared
with ropivacaine alone: a randomized, double-blinded, con-
trolled study. Anesth Analg 2003;97:70612
11. Guidry OF. Deja vu. Anesth Analg 2010;110:6512
12. Lynch DK. Plan ahead. Anesth Analg 2010;110:6534
Table 2. Challenges of Earthquakes in Haiti and
Wenchuan, China
Challenge Haiti Wenchuan, China
Water Previously not drinkable Previously drinkable
Tropical diseases Prevalent Not prevalent
Language barrier Yes No
Travel From out of country In country
Security Potentially dangerous Not dangerous
Drugs Multiple names/doses No confusion
Anesthesia in Haiti
December 2010 Volume 111 Number 6 www.anesthesia-analgesia.org 1449