In the wake of the January 2010 earthquake in Haiti, the International Federation of Red Cross and Red Crescent Societies (IFRC) mobilised the biggest single-country emergency response operation it had ever mounted. Deployments included field hospitals, one of which was a specially designed rapid response mobile and light hospital with 30 expatriate staff. This was initially set up in Port-au-Prince at the main university hospital, and later relocated to Petit Goave in the south-west of Haiti. This article describes the lessons learned during the hospital deployment.
The RDEH ERU
The Rapid Deployment Emergency Hospital is a health Emergency Response Unit (RDEH ERU) and one of the IFRCs global emergency response standby tools. The unit is positioned in Oslo and owned and managed by the Norwegian Red Cross. The standard configuration is a tented 20-bed medical/surgical facility, with medical supplies and its own facilities for power generation, lighting, water purification, sanitation and telecommunications, along with vehicles and a base camp for staff. The standard set-up requires 1214 specially trained personnel. In the case of Haiti, additional medical supplies, tents, beds, relief items and two ambulances were provided to support local hospitals.
The RDEH is designed to be loaded into one Ilyushin 76 cargo plane, but due to lack of availability the unit was divided between two smaller Antonov cargo planes and a Boeing 747. The Antonovs landed in Port-au-Prince and the Boeing in Santa Domingo, from where items were trucked into Haiti. Self-offloading aircraft like Ilyushins and Atonovs are preferred as off-loading equipment is often not available in emergency contexts. The expanded multinational team of 30 (from Norway, Canada, Israel and Denmark) included two surgical teams, one outpatient team, a midwife, nurses, technicians, administrators, community health specialists, psychosocial support specialists and paramedics. They arrived between 15 and 19 January.
The ERU was set up in the grounds of the University Hospital in Port-au-Prince. An advance team of two arrived from Norway 24 hours ahead of the unit, and identified the site along with the IFRC Field Assessment and Coordination Team (FACT). The first patients were treated in the out-patient department on 16 January, and surgery commenced on 18 January. The outpatient department treated an average of 7080 people per day, dealing with major dressing changes and wound care and management. A total of 300 surgical procedures were performed.
The ERU team set up its base camp in the hospital compound and remained there for the duration of the four-week mission, providing surgery, an outpatient clinic, psychosocial support to patients and local staff, epidemic prevention measures and material help and technical advice to the hospital management. The hospital was provided with over 800m2 of tenting, 100 quick-set-up beds, blankets, plastic sheeting, a portable X-ray machine, a generator, a laboratory module and medical supplies.
The hospital compound comprised over 25 buildings, with 700 beds and approximately 2,000 staff. Some structures, such as the nursing school, had totally collapsed, while others were partially damaged and not usable (including paediatrics, maternity and some operating rooms). Post-quake, the compound contained over 1,400 people, including patients, their families and staff. Repeated after-shocks forced patients and staff out of the remaining buildings and further complicated patient care and hospital management. Many patients and their families were exposed to the elements for many days as tents and shelters were being set up. Many international aid agencies had teams in place working during daylight hours, using salvageable hospital spaces and tented facilities. Daily coordination meetings were held involving aid agencies and the hospital management team.
The RDEH ERU Operating Theatre was the best and most equipped facility on the hospital campus. It enabled the team to handle a large proportion of procedures requiring a proper clean (semi-sterile) environment, such as caesarean sections and emergency laparotomies. The surgical team operated in close collaboration with other agencies working at the hospital, selecting patients from a common pool and returning them to wards on the hospital grounds after surgery. The RDEH had to run its own recovery services. A full complement of ward nursing staff was neither locally available nor provided for in the RDEH set-up. An experienced nurse originally designated to work with children had to take charge of this facility, which functioned efficiently, and expatriate paramedics provided post-operative care. Future deployments require better staffing for post-operative nursing care.
The ERUs psychosocial support component comprised two trained delegates and a supporting kit. The first task upon arrival was to provide psychological first aid (PFA) and emotional support for patients and relatives. Applying a community-based approach, delegates recruited and trained a team of 20 Haiti Red Cross volunteers to provide PFA and other basic psychosocial services to patients and others in need. The volunteers learned to listen to patients and observe behaviour so as to identify people showing signs of mental health distress or symptoms of disorder. When identified, patients were evaluated by the psychosocial delegate, to decide whether follow-up was needed. Additional activities included visiting and interacting with patients on wards, following up on specific requests by hospital colleagues and awareness-raising on normal reactions to abnormal events.
The psychosocial delegates and their volunteer teams established a protocol to ensure the protection and care of unaccompanied minors and isolated children. A child-friendly space was set up, with structured playing and activities that allowed the children to regain a sense of normality. A social space was also set up in the hospital grounds, with games and recreational equipment to enable socialising and an opportunity to talk. This was used by hospital staff, patients, visitors and relatives.
In the paediatric unit, particular attention was given to parents and children, to reinforce parenting skills and re-establish daily routines through games that stimulated psychomotor development. Creative activities such as the establishment of a childrens choir and an exhibition of drawings helped raise spirits in the hospital and bolstered mechanisms of social support. Ensuring the wellbeing of volunteers and local hospital staff was another psychosocial activity. Delegates ensured supervision and support for volunteers as they were as affected by the earthquake as those they were assisting.
After three weeks, the situation within and outside the hospital had stabilised, and the psychosocial team established contact with communities surrounding the facility. Delegates trained three groups of community workers from the NGO Médecins du Monde and hospital staff, to enable them to continue providing services in the longer term.
Epidemic prevention and community health
The Community Health Module (CHM) comprised two trained delegates and a supporting kit with Information, Education and Communications (IEC) material for epidemic hazard mapping and priority activities focused on disease prevention. The urgency of medical needs following the earthquake dictated that, for the first few days, all medical staff (CHM delegates included) provided care for injured patients. CHM delegates also worked with the sanitation committee at the University Hospital to address poor hygiene and sanitation conditions.
CHM delegates focused on three basic health messages: hand washing, safe disposal of waste (including use of latrines) and drinking safe (potable) water. Haitian Red Cross Volunteers were trained in hygiene promotion, targeting the population living in informal IDP camps. Activities were initially carried out with the 1,400 patients and family members within the hospital compound. In early February, the Haitian government asked the IFRC to vaccinate a population of 150,000 IDPs, as part of a mass vaccination campaign. CHM delegates trained 110 Haitian Red Cross vaccinators, and assisted in the planning and implementation of the campaign.
After approximately four weeks, the RDEH was moved to a rural hospital in Petit Goave. This area had also been severely affected by the earthquake, but had not received as much attention as the capital. CHM delegates carried out assessments of health and hygiene conditions in IDP camps. Training of new Haitian Red Cross Volunteers in hygiene promotion activities continued, and hygiene promotion activities were carried out with over 2,000 families in 13 IDP camps. Training was coordinated with Oxfam.
The success of epidemic prevention activities was due largely to very close cooperation with the Haitian Red Cross, whose Volunteers proved to be a tremendous asset. Many were already trained and their local knowledge and acceptance by the population greatly facilitated their work. The Volunteers were able to communicate effectively with the target population, particularly since they were enduring the same losses and hardships. Training both Red Cross and community members (community mobilisers, health committees) improves the prospects for sustainability.
Most of the IDP camps assessed in Petit Goave had neither potable water nor sufficient, if any, latrines. This made it difficult to convey hygiene messages when hygiene promoters could offer only good advice and soap. Ideally, there should be closer coordination with actors providing water, sanitation and shelter. The provision of hygiene kits would also improve matters.
The hardware of the RDEH ERU was ideally suited for this type of disaster response, as it was configured for rapid deployment and quick set-up, with lighter, smaller medical and non-medical components than traditional mobile hospitals. The ability to rapidly set up and perform safe surgery within hours was critical to saving many lives at the University Hospital. The ability to move once the situation had stabilised was likewise critical to providing continued care at another location.
Working 16 to 18 hours a day in very difficult circumstances meant that the flexibility and hardiness of the specially trained medical and non-medical ERU members, drawn from four nations and with a mix of skills and backgrounds, were crucial to the missions success. Most had undergone specialised ERU and Field School training. At the beginning, all delegates were required to participate in all set-up tasks, including off-loading and erecting tents in addition to providing safe and good-quality medical care. Explicitly pairing experienced delegates with less experienced ones in mentoring roles has proved to be successful as a training methodology. The need for post-operative care and ward nursing was critical, and future deployments need to ensure sufficient personnel providing such care utilising both nurses and paramedics. The many surgical teams working at the University Hospital overlooked the post-operative end, with minimal or no care due to the lack of nurses. Additionally, and perhaps most critically, the ability of the team to work in close collaboration and coordination with local hospital management, the Haitian Red Cross leadership and Volunteers and other international providers increased the efficiency and effectiveness of the entire relief effort. Such interventions need to operate in support of local medical teams, no matter how basic, as an explicit objective.
After-shocks limited the extent to which existing structures could be used, both due to potential collapse and the psychological trauma and fear experienced by staff and patients, and hospital managers were not able to order patients or staff into these structures for several weeks. First-phase responders need to bring sufficient supplies and shelter for themselves and their patients, as well for the services they wish to provide, or they risk becoming a burden and further depleting local resources. The RDEH was the only unit deployed to the University Hospital that was entirely self-sufficient and thus did not put further strain on already weakened infrastructure and staff. Surgery and outpatient care provide a platform for epidemic control measures and psychosocial support activities. Thus, the RDEH ERU maximised its impact by going beyond clinical care. Providing expert advice in running field hospitals, and supporting but not substituting for hospital managers, proved vital and enabled the RDEH to move to another location.
Hossam Elsharkawi, PhD (Hossam.Elsharkawi@redcross.ca), is Director, Emergencies and Recovery, Canadian Red Cross. Toerris Jaeger is Head of Disaster Management at the Norwegian Red Cross. Lene Christensen, MA, is Knowledge Management Adviser, Danish Red Cross. Eleanor Rose, RN, BScN, is Canadian Red Cross Community Health Delegate and Travel Health Advisor. Karine Giroux Delegate for the Psychosocial Support Programme in the ERU, Canadian Red Cross.
Brynjulf Ystgaard is a surgeon and Norwegian Red Cross Delegate.