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Trial by Fire

Thursday February 4, 2010
A girl pulled from the rubble with a crushed femur recovers in the University of Miami’s tent.
A girl pulled from the rubble with a crushed femur recovers in the University of Miami’s tent.
(Photo by Randall Browning, RN)
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American nurses who went to Haiti in the immediate aftermath of the earthquake that struck the island nation last month say they used common sense, basic nursing skills, and whatever equipment and materials were on hand to care for Haitians with minor to life-threatening injuries.

“I used good, old-fashioned community health nursing skills, like you learn in school,” says Donna Martsolf, RN, a professor of nursing at Kent State University in Ohio.

Martsolf and her physician husband, Robert, were supposed to be in Haiti for two days when the earthquake hit about an hour after they landed at the Port-au-Prince airport. Martsolf was there to visit the first baccalaureate nursing school in Haiti that she helped establish in the village of Leogane.

Because of the quake, the couple never reached the school. Instead, they spent the first night working with members of Doctors Without Borders/Medecins Sans Frontieres in the relief agency’s administrative offices providing first aid to Haitians with broken bones, lacerations and other injuries. They used cardboard boxes and pieces of wood pallets as splints held together with ace bandages to immobilize compound fractures. “We were working hard just to get the bones in some approximation of alignment,” she says.

Supply Challenges
Most of the nurses interviewed by Nursing Spectrum arrived with humanitarian relief agencies or other organizations. They were located at hospitals in varying states of disrepair in different parts of the country. Supplies, they say, were not necessarily scarce, they were just stored in locations that were not easily accessible.

Randall Browning, RN, BSN, from Fort Lauderdale, Fla., says he surrendered his belt shortly after arriving in Haiti so it could be used as a tourniquet, made makeshift foley bags from IV tubing and plastic jugs, and used central-line catheters and foleys as chest tubes.

“There was a lot of jury-rigging going on,” says Browning, who worked part of the time in a field hospital set up by the University of Miami. Browning went to Haiti independently with a physician who makes multiple relief trips to the country.

“We intended to go immediately to the rural areas, but when we saw the chaos at the field hospital, we couldn’t leave,” he says.

Although pallets of supplies were nearby, no one was distributing the material. Healthcare workers dug through the supplies looking for what they needed, leaving the rest in a heap. Also, the equipment was often incompatible because it was sent from different countries, Browning says. There were sets of needleless tubing and tubing that required needles. “We never had enough needles,” he says. “We had to be creative, putting anything we could at the end of the tubing and then taping it all together.”

One of the first things that Kevin Armstrong, RN, MScN, and Christopher O’Connell, RN, both of Dartmouth Hitchcock-Medical Center in New Hamphire, had to improvise was a PACU. They were part of a nine-member medical team sent from Dartmouth to Haiti after the quake. The team traveled by car to St. Therese Hospital run by the Haitian ministry of health in the central plateau of Hinche near the border of the Dominican Republic.

Even though it was a government-run hospital, they found the facility lacked basic medical equipment and supplies, had limited electricity, no running water and was filthy. There were only two blood-pressure cuffs for the hospital and one oxygen regulator. The hospital’s focus, they learned, was on HIV/AIDS education and care, not the surgical trauma cases the team would be handling.

Although there was an OR, Armstrong and O’Connell found there was no PACU; surgical patients usually recovered in the OR. “We assessed that one of the first things nurses could do was to establish a PACU to make surgery more efficient,” Armstrong says. O’Connell, Armstrong and the third nurse on their team, Michael Hawkins, CRNA, searched the hospital for a suitable room not too far from the OR. The first room they chose did not have reliable electricity so they moved to a room that was used as a library but that had consistent electricity in one outlet.

“We felt the most crucial capabilities for us would be supplemental oxygen, suction and pulse oximetry,” Armstrong says. O’Connell would travel to Port-au-Prince to hunt through medical warehouses for equipment they needed for the OR and PACU.

The 90-year-old hospital’s hallways were located outside and covered with tin roof porticoes. There were no doors on the PACU and often chickens or dogs would walk past, oblivious to the nurses and their patients, says O’Connell.

Traumatic Amputations
Michael Braden, RN, an OR nurse from Seattle who works with MSF, was assigned to a maternity hospital in a poor neighborhood of Port-au-Prince. But traumatic amputation, not C-sections, was the surgical procedure MSF personnel performed most often, he says. The group had to buy a hacksaw to perform the amputations.

“We provided pretty basic nursing care,” Braden says. “The work takes you right back to the beginnings of nursing. But one thing you still can do is provide comfort and hold a hand.”

With limited surgical instrumentation, anesthetic agents, bandages, medications and masks, the surgeons and nurses worked with what they had. “We just did without,” says Braden, who has also been on MSF missions in Nigeria and Sri Lanka. “We would use the same mask all day. We soaked instruments in betadine, used hemostats for needle holders and made do with bad scissors. We had enough of everything, but it wasn’t quite right.”

The nurses said the amputations were emotionally trying for the patients and for themselves. “It was the most difficult thing I had to witness; having a conversation with someone about amputating an arm or a leg,” says Heather Bedlion, RN, a cardiac surgery staff nurse at Brigham and Women’s Hospital in Boston who traveled to Haiti with Boston-based Partners In Health.

Bedlion, who was sent to St. Mark’s Hospital, says the Haitian staff was not used to seeing so many amputations and had to be educated as to why they were necessary. “There was a subtle tension that we were coming in and amputating everyone’s legs,” she says. “We tried to educate them and tell them if we don’t do the amputations the infections could kill the patients.”

It seemed that every other patient had compartment syndrome, Braden says. “Most of these early patients had been trapped with debris laying on them and gangrene had already set in by the time they reached us. We weren’t doing any fasciotomies, we were just amputating as fast as we could.”

The nurses in Bedlion’s group helped Haitian personnel develop charting and assessment systems that identified patients, their diagnoses and where they were located in the hospital to make their work easier.

Armstrong and O’Connell, through an interpreter, taught the Haitian nurses about simple postoperative care and conducted basic patient and family education. And although the Haitian medical director had at first been skeptical about the PACU, by the time the nurses left, he was proudly showing it to the newly arrived medical team.

Janet Boivin, RN, is a staff writer for Nursing Spectrum.


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The Right Stuff for Disaster Nursing

Many nurses, touched by the images of injured children and adults in Haiti, may feel compelled to travel there or to try disaster relief nursing in other countries facing a health crisis. But nurses who have done this kind of work say it takes more than nursing skills, good intentions and a plane ticket to alleviate the suffering of disadvantaged people. Here is some of their advice.

“The work is extremely rewarding but also extremely disturbing. It is its own reward and punishment. Be flexible and use what is in front of you. The nursing is as basic as it can get. If you want a chance to help people, then try an organization like Doctors Without Borders/Medecins San Frontieres.” — Michael Braden, RN, an OR nurse from Seattle who is in Haiti with MSF

“Be ready to live austerely and to live without things like sleep and the basic amenities. It’s not pleasant. You need to be prepared to be tough and adaptable. The road we traveled on in Haiti would have been enough to send people home screaming.” — Christopher O’Connell, RN, a flight nurse with Dartmouth Hitchcock Advanced Response Team in New Hamphire and an Army Reserve Nurse who has served in Iraq

“The best advice I can give you is that it is not about you. It’s about the people you are there to support. Don’t forget it is their country, their culture, and their way of life and you are there to help them get what they need.” — Heather Bedlion, RN, Brigham and Women’s Hospital in Boston, who spent almost two weeks in Haiti after the earthquake