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Special Report
Haiti: After the Fall
August 2010
As you read this, it has been a little more than 7 months since the earthquake devastated Port-au-Prince specifically, and all of Haiti in general. Others in this issue have discussed the immediate disaster, the massive response to it, and the challenges faced by all who chose to go to help. Many wound care providers answered the call and did what they could to relieve the suffering and improve the situation. Their efforts proved invaluable to those who were suffering the most. Time has passed, yet many questions still remain: what is going on now? Has anything changed in 7 months? Is the country rebuilding? What is the state of the medical facilities in Port-au-Prince?
The situation seemed to stabilize after the disaster, and local physicians, nurses, physical therapists, and other healthcare professionals were providing more health care. It soon became apparent that they were in need of additional training if they were going to be able to manage the high volume of patients with wounds. The Minister of Health in Haiti and the Medical Association of Haiti contacted the World Association of Wound and Lymphedema Care (WAWLC) to present a wound care educational and training program for the Haitian healthcare providers. The Secretariat of the WAWLC is Dr. John Macdonald and the President is Dr. David Keast of Canada. The program was scheduled for July 7–9, 2010 in Port-au-Prince, Haiti.
Since I had assisted with our similar program in Ghana, Africa, I was asked to determine the curriculum for the course. I quickly realized that the curriculum needed revision since the Haitians needed much more help with managing acute wounds and the long-term care of complications of acute wounds than did the Ghanaians. They would obviously still need the instruction in the care of chronic wounds, but their current need centered around acute wound management. Once the topics were selected, the faculty was chosen and included: Barbara Bates-Jensen, PhD, RN, from California, Ms. Janice Young, RN, from Texas, Dr. John Macdonald, from Florida, and me.
We spent our July 4th holiday working our way from home to Port-au-Prince, arriving on Monday, July 5. As we were being driven from the airport to the place where we were to stay, we were amazed—it looked as if the earthquake could have been the day before. Streets were still blocked with rubble, many collapsed buildings seemed untouched, tent cities were everywhere, and yet people seemed to be going ahead with life as usual, walking around the mess as if it were normal (Figures 1–3). There appeared to be very few organized efforts to clean up.
We were honored to be hosted in a private home, which had suffered minor damage but was livable. Our hosts went above and beyond the call of duty to see that we were comfortable despite some “less than optimal” circumstances.
After unloading our wares, we were taken to the Mevs Hospital in Port-au-Prince to assess the current situation. The University of Miami and Project Medishare were helping to staff and manage the hospital. The treatment areas were very crowded with patients and healthcare providers, but all were trying to do what they could to relieve suffering. The wound care center was a small building crowded with patients (Figure 4). There were only 2 treatment areas in the small building. As soon as I walked in, a young lady, whom I later found out was a medical student, asked me to look at a baby girl with a thigh wound. She asked me what to do with the wound even though it appeared to be healed. The parents of the child were concerned because of a hard “mass” under the scar. After examining the child, I suggested that the scar be opened and the mass be removed. She asked me to supervise the procedure. She did an excellent job and quickly removed the mass—a bullet—from the child’s leg (Figure 5). The family had no idea how it got there! The interesting thing to me was that there was only an entrance wound and no exit wound. This bullet was fired from a long distance before it hit the child, or it went through several other objects before hitting her. The wound was dressed and the child scheduled for follow-up (Figure 6).
Dr. Bates-Jensen and I were asked to see a new patient who had just been brought to the spinal cord injury portion of the facility. This young man was a paraplegic who had been abandoned by his family after the earthquake. Someone found and brought him to the hospital. He was dehydrated, malnourished, and horribly infected. He had huge pressure ulcers on his buttocks and ischial areas and an abscess of one leg extending from his buttock to just above his knee. I asked the physician in the center what was to be done for him. He looked at me and said, “Whatever you do for him is what will be done.” To say I was shocked is an understatement: this volunteer physician had no idea what to do for this patient! Since his initial treatment seemed to be up to Dr. Bates-Jensen and me, we talked to the patient, told him what we needed to do, and proceeded to debride the ulcers and drain the abscess. There was a group of nurses and the physician watching us as we prepared to start, but after a few minutes of work, I looked up and everyone was gone! They were nowhere to be found; we were obviously on our own. We did what we could, dressed the wounds with betadine-soaked dressings (which we were lucky to find), and went to find the physician to write some orders for the patient’s continued care. When we found him, he said he wasn’t writing the orders; we would have to do it. We finally found someone to take some orders before we left the area very discouraged about what we had seen and doubtful about the patient’s outcome. The need for wound care education could not have been more apparent, and these were the volunteers mostly from the United States!
The site for the conference was a local hotel and conference center. Unfortunately, the hotel was severely damaged and was not usable, but the conference center had suffered only minimal damage. The hurdle of where to have the course had been cleared; the remaining question was if anyone would attend the course. There had been nearly 45 physicians, nurses, physical therapists, and other healthcare providers sign up for the course, but we were concerned about people being able to get to the program. On the first morning, our fears were quickly relieved—more than 45 people arrived for the conference. We were very pleased.
The course curriculum is based on the beliefs of the WAWLC that the first wound care instruction must emphasize the basics. If one has minimal wound care management knowledge, basic principles will serve as a safe, reliable foundation of information for the treatment of patients with wounds. The 5 basic principles include: 1) enhance systemic conditions, 2) protect the wound from trauma, 3) promote a clean wound base and prevent infection, 4) maintain a moist environment, and 5) control periwound edema and lymphedema. We have found that these principles are a good starting point for training practitioners to manage all types of wounds, and would be of benefit to many in the United States. The course topics and presenters appear in Table 1.
On the afternoon of the second day of the program, hands-on sessions were taught for compression bandaging and application of negative pressure wound dressings. Everyone seemed to have a great time wrapping each others legs with compression bandages and cutting black foam to fit a “wound” drawn on a piece of paper. The 4 of us were exhausted from running around checking on the group’s progress. In addition to having fun, we are all convinced that the participants could manage negative pressure wound dressings and compression bandages in “real” circumstances.
At the conclusion of the 3-day program we had graduation. Each of the participants was given a certificate of completion of the course and a group photograph was taken (Figure 7). We felt a certificate was important so that each of the participants could show that he/she had attended the basic wound care course and had additional knowledge in wound care that non-participants missed. As we sent them out to manage patients with wounds in their facilities, we could not help but be encouraged by their enthusiasm. We hope their excitement will be contagious and will encourage others to attend the next wound course we are able to provide.
As is true with any teaching endeavor, there is more to do. Follow-up and additional teaching will be essential to the success of this program. Book learning is important, but applying it is critical. We hope to return to Haiti in the near future to go into the hospital and do some bedside teaching. This is where the teaching can truly make a difference. There are other opportunities of which we hope to take advantage in the near future. The medical school and residency programs need textbooks on wound care; it seems we could all help with that problem. If you have books you could donate or would like to contribute to that project, please let me know at TATread@aol.com. There is so much need and so few resources. The nursing shortage there is acute. Even before the earthquake more nurses were needed, but the earthquake destroyed the nursing school, killing most of the current class of nursing students and a large portion of the faculty. Who will be there to teach the next generation of nurses? Who will encourage students to go into nursing so that the need can be met?
There is still much work to be done in Haiti. We met many Haitian physicians and other healthcare providers who are tirelessly giving of their skills and resources to help their fellow Haitians. Surely we can do more to assist them in this monumental struggle.
The situation seemed to stabilize after the disaster, and local physicians, nurses, physical therapists, and other healthcare professionals were providing more health care. It soon became apparent that they were in need of additional training if they were going to be able to manage the high volume of patients with wounds. The Minister of Health in Haiti and the Medical Association of Haiti contacted the World Association of Wound and Lymphedema Care (WAWLC) to present a wound care educational and training program for the Haitian healthcare providers. The Secretariat of the WAWLC is Dr. John Macdonald and the President is Dr. David Keast of Canada. The program was scheduled for July 7–9, 2010 in Port-au-Prince, Haiti.
Since I had assisted with our similar program in Ghana, Africa, I was asked to determine the curriculum for the course. I quickly realized that the curriculum needed revision since the Haitians needed much more help with managing acute wounds and the long-term care of complications of acute wounds than did the Ghanaians. They would obviously still need the instruction in the care of chronic wounds, but their current need centered around acute wound management. Once the topics were selected, the faculty was chosen and included: Barbara Bates-Jensen, PhD, RN, from California, Ms. Janice Young, RN, from Texas, Dr. John Macdonald, from Florida, and me.
We spent our July 4th holiday working our way from home to Port-au-Prince, arriving on Monday, July 5. As we were being driven from the airport to the place where we were to stay, we were amazed—it looked as if the earthquake could have been the day before. Streets were still blocked with rubble, many collapsed buildings seemed untouched, tent cities were everywhere, and yet people seemed to be going ahead with life as usual, walking around the mess as if it were normal (Figures 1–3). There appeared to be very few organized efforts to clean up.
We were honored to be hosted in a private home, which had suffered minor damage but was livable. Our hosts went above and beyond the call of duty to see that we were comfortable despite some “less than optimal” circumstances.
After unloading our wares, we were taken to the Mevs Hospital in Port-au-Prince to assess the current situation. The University of Miami and Project Medishare were helping to staff and manage the hospital. The treatment areas were very crowded with patients and healthcare providers, but all were trying to do what they could to relieve suffering. The wound care center was a small building crowded with patients (Figure 4). There were only 2 treatment areas in the small building. As soon as I walked in, a young lady, whom I later found out was a medical student, asked me to look at a baby girl with a thigh wound. She asked me what to do with the wound even though it appeared to be healed. The parents of the child were concerned because of a hard “mass” under the scar. After examining the child, I suggested that the scar be opened and the mass be removed. She asked me to supervise the procedure. She did an excellent job and quickly removed the mass—a bullet—from the child’s leg (Figure 5). The family had no idea how it got there! The interesting thing to me was that there was only an entrance wound and no exit wound. This bullet was fired from a long distance before it hit the child, or it went through several other objects before hitting her. The wound was dressed and the child scheduled for follow-up (Figure 6).
Dr. Bates-Jensen and I were asked to see a new patient who had just been brought to the spinal cord injury portion of the facility. This young man was a paraplegic who had been abandoned by his family after the earthquake. Someone found and brought him to the hospital. He was dehydrated, malnourished, and horribly infected. He had huge pressure ulcers on his buttocks and ischial areas and an abscess of one leg extending from his buttock to just above his knee. I asked the physician in the center what was to be done for him. He looked at me and said, “Whatever you do for him is what will be done.” To say I was shocked is an understatement: this volunteer physician had no idea what to do for this patient! Since his initial treatment seemed to be up to Dr. Bates-Jensen and me, we talked to the patient, told him what we needed to do, and proceeded to debride the ulcers and drain the abscess. There was a group of nurses and the physician watching us as we prepared to start, but after a few minutes of work, I looked up and everyone was gone! They were nowhere to be found; we were obviously on our own. We did what we could, dressed the wounds with betadine-soaked dressings (which we were lucky to find), and went to find the physician to write some orders for the patient’s continued care. When we found him, he said he wasn’t writing the orders; we would have to do it. We finally found someone to take some orders before we left the area very discouraged about what we had seen and doubtful about the patient’s outcome. The need for wound care education could not have been more apparent, and these were the volunteers mostly from the United States!
The site for the conference was a local hotel and conference center. Unfortunately, the hotel was severely damaged and was not usable, but the conference center had suffered only minimal damage. The hurdle of where to have the course had been cleared; the remaining question was if anyone would attend the course. There had been nearly 45 physicians, nurses, physical therapists, and other healthcare providers sign up for the course, but we were concerned about people being able to get to the program. On the first morning, our fears were quickly relieved—more than 45 people arrived for the conference. We were very pleased.
The course curriculum is based on the beliefs of the WAWLC that the first wound care instruction must emphasize the basics. If one has minimal wound care management knowledge, basic principles will serve as a safe, reliable foundation of information for the treatment of patients with wounds. The 5 basic principles include: 1) enhance systemic conditions, 2) protect the wound from trauma, 3) promote a clean wound base and prevent infection, 4) maintain a moist environment, and 5) control periwound edema and lymphedema. We have found that these principles are a good starting point for training practitioners to manage all types of wounds, and would be of benefit to many in the United States. The course topics and presenters appear in Table 1.
On the afternoon of the second day of the program, hands-on sessions were taught for compression bandaging and application of negative pressure wound dressings. Everyone seemed to have a great time wrapping each others legs with compression bandages and cutting black foam to fit a “wound” drawn on a piece of paper. The 4 of us were exhausted from running around checking on the group’s progress. In addition to having fun, we are all convinced that the participants could manage negative pressure wound dressings and compression bandages in “real” circumstances.
At the conclusion of the 3-day program we had graduation. Each of the participants was given a certificate of completion of the course and a group photograph was taken (Figure 7). We felt a certificate was important so that each of the participants could show that he/she had attended the basic wound care course and had additional knowledge in wound care that non-participants missed. As we sent them out to manage patients with wounds in their facilities, we could not help but be encouraged by their enthusiasm. We hope their excitement will be contagious and will encourage others to attend the next wound course we are able to provide.
As is true with any teaching endeavor, there is more to do. Follow-up and additional teaching will be essential to the success of this program. Book learning is important, but applying it is critical. We hope to return to Haiti in the near future to go into the hospital and do some bedside teaching. This is where the teaching can truly make a difference. There are other opportunities of which we hope to take advantage in the near future. The medical school and residency programs need textbooks on wound care; it seems we could all help with that problem. If you have books you could donate or would like to contribute to that project, please let me know at TATread@aol.com. There is so much need and so few resources. The nursing shortage there is acute. Even before the earthquake more nurses were needed, but the earthquake destroyed the nursing school, killing most of the current class of nursing students and a large portion of the faculty. Who will be there to teach the next generation of nurses? Who will encourage students to go into nursing so that the need can be met?
There is still much work to be done in Haiti. We met many Haitian physicians and other healthcare providers who are tirelessly giving of their skills and resources to help their fellow Haitians. Surely we can do more to assist them in this monumental struggle.
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