Ofer Merin

The Israeli Field Hospital in Haiti — Ethical Dilemmas in Early Disaster Response

Dr. Ofer Merin and colleagues write that every mass-casualty event raises ethical issues concerning the priorities of treatment, but the Haiti disaster was exceptional in several ways.

Early Disaster Response in Haiti: The Israeli Field Hospital Experience

The earthquake that struck Haiti in January 2010 caused an estimated 230,000 deaths and injured approximately 250,000 people. The Israel Defense Forces Medical Corps Field Hospital was fully operational on site only 89 hours after the earthquake struck and was capable of providing sophisticated medical care. During the 10 days the hospital was operational, its staff treated 1111 patients, hospitalized 737 patients, and performed 244 operations on 203 patients. The field hospital also served as a referral center for medical teams from other countries that were deployed in the surrounding areas. The key factor that enabled rapid response during the early phase of the disaster from a distance of 6000 miles was a well-prepared and trained medical unit maintained on continuous alert. The prompt deployment of advanced-capability field hospitals is essential in disaster relief, especially in countries with minimal medical infrastructure. The changing medical requirements of people in an earthquake zone dictate that field hospitals be designed to operate with maximum flexibility and versatility regarding triage, staff positioning, treatment priorities, and hospitalization policies. Early coordination with local administrative bodies is indispensable.

Orthopaedic management in a mega mass casualty situation. The Israel Defence Forces Field Hospital in Haiti following the January 2010 earthquake

Following the January 2010 earthquake in Haiti, the Israel Defence Forces (IDF) established a field hospital in Port au Prince. The hospital started operating 89 h after the earthquake. We describe the experience of the orthopaedic department in a field hospital operating in an extreme mass casualty situation. The hospital contained 4 operating table and 72 hospitalization beds. The orthopaedic department included 8 orthopaedic surgeons and 3 residents. 1111 patients were treated in the hospital, 1041 of them had adequate records for inclusion. 684 patients were admitted due to trauma with a total of 841 injuries. 320 patients sustained 360 fractures, 18 had joint dislocations and 22 patients were admitted after amputations. 207 patients suffered 315 soft tissue injuries. 221 patients were operated on under general or regional anaesthesia. External fixation was used for stabilization of 48 adult femoral shaft fractures, 24 open tibial fractures and 1 open humeral fracture. All none femoral closed fractures were treated non-operatively. 18 joint reductions and 23 amputations were performed. Appropriate planning, training, operational versatility, and adjustment of therapeutic guidelines according to a constantly changing situation, enabled us to deliver optimal care to the maximal number of patients, in an overwhelming mass trauma situation.

Collaboration in Response to Disaster — Typhoon Yolanda and an Integrative Model

An Israeli medical relief team that usually deploys a freestanding, self-sufficient field hospital found in the Philippines that when a local facility is partly functional, there are important short- and long-term benefits to full integration with the local units.

Application of information technology within a field hospital deployment following the January 2010 Haiti earthquake disaster

Following the January 2010 earthquake in Haiti, the Israel Defense Force Medical Corps dispatched a field hospital unit. A specially tailored information technology solution was deployed within the hospital. The solution included a hospital administration system as well as a complete electronic medical record. A light-weight picture archiving and communication system was also deployed. During 10 days of operation, the system registered 1111 patients. The network and system up times were more than 99.9%. Patient movements within the hospital were noted, and an online command dashboard screen was generated. Patient care was delivered using the electronic medical record. Digital radiographs were acquired and transmitted to stations throughout the hospital. The system helped to introduce order in an otherwise chaotic situation and enabled adequate utilization of scarce medical resources by continually gathering information, analyzing it, and presenting it to the decision-making command level. The establishment of electronic medical records promoted the adequacy of medical treatment and facilitated continuity of care. This experience in Haiti supports the feasibility of deploying information technologies within a field hospital operation. Disaster response teams and agencies are encouraged to consider the use of information technology as part of their contingency plans.

Triage in Mass-Casualty Events: The Haitian Experience

INTRODUCTION Mass-casualty triage is implemented when available resources are insufficient to meet the needs of all patients in a disaster situation. The basic principle is to do the maximum good for the most casualties with the least amount of resources. There are limited data to support the applicability of this principle in massive disasters such as the January 2010 earthquake in Haiti, in which the number of patients seeking medical attention overwhelmed the local resources. OBJECTIVE To analyze the application of a triage system developed for use in a mass-casualty setting with limited resources. The system was designed to admit only those patients who had medical conditions requiring urgent treatment that were within the capabilities of the hospital and had a good chance of survival after discharge. Priority was given to those whose treatment could be administered within a short hospital stay. METHOD A retrospective, observational review of computerized registration forms of Haitian earthquake victims who sought medical care at a 72-bed field hospital within four to 14 days after the event. An analysis of the efficacy of the triage protocol that was used followed, using length of hospital stay to measure consumption of resources. RESULTS A total of 1,111 patients were triaged for treatment in the field hospital within 14 days of the earthquake. The median length of stay for all patients for whom data was available was 16 hours (mean = 29.7 hours). The majority of patients (n = 620, 65%) were discharged within 24 hours. Two hundred five patients underwent surgery and were discharged within a median of 39 hours (mean = 52.6 hours); of these, 124 (62%) were discharged within 48 hours. The total mortality of the treated patients was 1.5% (n = 17). CONCLUSIONS Currently accepted triage principles for the most part are appropriate for efficiently providing medical care in a disaster area with extremely limited resources, but require extensive adaptation to local conditions.

Hard times call for creative solutions: medical improvisations at the Israel Defense Forces Field Hospital in Haiti

The leadership in each jurisdiction of the world has been described as legally, morally, and politically responsible for ensuring that necessary and appropriate actions are taken to protect people and property from the consequences of emergencies and disasters. As emergencies often evolve rapidly and become too complex for effective improvisation, a government can successfully discharge its emergency management responsibilities only by taking action beforehand. This requires preparedness in advance of the disaster event. Accordingly, preparedness measures should not be improvised or handled on an ad hoc basis.

Lessons learned from an obstetrics and gynecology field hospital response to natural disasters.

Field hospitals were deployed by the Israel Defense Forces as part of the international relief efforts after major seismic events, one in Haiti (2010) and one in Japan (2011). The teams treated a total of 44 pregnant and 24 nonpregnant women and performed 16 deliveries and three cesarean deliveries under extreme conditions. Half of all deliveries were complicated by preeclampsia and 31% were preterm (at 30-32 weeks of gestation). It is imperative that obstetrician-gynecologists be included among humanitarian aid delegations sent to sites of natural disasters. The complicated cases we encountered required highly skilled obstetricians and led to a shortage of specific medications for these women. Cases that would have been considered routine under normal conditions created unanticipated ethical and practical issues in the face of very limited resources. The aim of this commentary is to share the experiences and lessons learned by our field hospital obstetrics and gynecology teams after the major earthquakes in Haiti and Japan. We present what we consider to be the 10 most important lessons learned and propose that they serve as guidelines in preparing for essential needs in other natural disaster settings.

Spontaneous Tension Pneumothorax

A 19-year-old man presented to the emergency department with shortness of breath and pain on the right side of the chest. He reported no history of trauma, smoking, or respiratory illness. On physical examination, his respiratory rate was 40 breaths per minute; oxygen saturation, 97%; and heart rate, 130 beats per minute.

Challenges in Implementing International Standards for the Field Hospital Emergency Department in a Disaster Zone: The Israeli Experience

BACKGROUND Medical response to world disasters has too often been poorly coordinated and nonprofessional. To improve this, several agencies, led by the World Health Organization (WHO), have developed guidelines to provide accreditation for Foreign Medical Teams (FMTs). There are three levels, with the highest known as FMT Type-3 providing outpatient as well as inpatient surgical emergency care in addition to inpatient referral care. In November 2016, the WHO certified the Israel Defense Forces Field Hospital as the first FMT Type-3. OBJECTIVES The objectives of this article are to describe the challenges in implementing these international standards for the field hospital emergency department in a disaster zone. DISCUSSION There are general standards for all levels of FMTs, as well as specific requirements for the FMT-3. These include a mechanism of appropriate triage, two operating suites, 40 regular beds, four to six intensive care unit beds, radiology facilities, and various staff specialties. Despite the sophistication of the field hospital, there are many challenges. Logistical challenges include constructing the hospital in a disaster zone and equipment issues. There are staff challenges such as becoming oriented to a new and difficult environment. Patient challenges include cultural differences, language barriers, and issues of follow-up. There are often ethical challenges unique to the disaster zone. CONCLUSION By presenting the experience and challenges of the first FMT Type-3, we hope that more countries can join this initiative and improve disaster care throughout the world.