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Hopkins Pediatric Team Leader Returns from Haiti

February 01, 2010

Hopkins Children’s emergency medicine physician Karen Schneider

Back from Haiti and reunited with the team of Hopkins Children’s residents she led to care for children in the aftermath of the earthquake January 12, pediatric emergency medicine physician Karen Schneider talked about an experience that has “still not sunk in.” Then she reported the surprising news that she would be leaving again Tuesday, February 2, with four nurses to take care of injured children in northern Haiti. There are now plenty of physicians in Port-au-Prince, she said, but the needs outside the capital city are great: “I still have something to offer, and I speak a little Creole, so I’m going back for another week to help.”

So, how did her first trip with a team of six pediatric residents begin? Schneider answered somewhat serendipitously as she had been preparing for weeks to leave for Haiti – one of four developing countries she takes pediatric residents to each year – the day after the 7.0-magnitude quake hit. Then, walking to her car late in the afternoon following a full-day shift in the ER, she got the news. At first she thought it was a joke.

“My first thought was the person sending this to me was teasing. But then I got text message after text message from different people and I’m thinking, ‘Oh my gosh, this is real,’” Schneider said. “It wasn’t until I got into the car and started listening to NPR [National Public Radio] that I realized the extent of what this was.”

Then, when she arrived home and turned on CNN, she saw the collapsed buildings and bodies in the rubble. Immediately she worried about the people she knew in Port-au-Prince through previous medical missions to Haiti, and who were to meet her and the team of residents the next day. Now, she realized, the trip designed to teach residents how to treat tropical conditions like scabies and worms was not going to happen. How would she even get to Haiti? She and the residents would be invaluable in helping to treat children injured in Haiti, but even if she was able to get there, how would she be able to house, feed and keep her team safe?

“We wouldn’t have the support, and there was no food or water in Port-au-Prince, so I knew we couldn’t do it,” Schneider said. “So I’m thinking where else can we go? Guyana? I have these residents for two weeks who are supposed to have this [tropical medicine] experience. All of a sudden I thought of my connections in the north of Haiti.”

Schneider was able to connect with her friends in the north, who immediately said yes, come. So she and the team changed their flight destination from Port-au-Prince to Cap Haitien in the north. But when they arrived at their connection in Ft. Lauderdale, they learned the FAA had cancelled all flights to Haiti. A Haitian-American friend in Miami put them up and hooked them up with the MediShare program at the University of Miami, and the next day Schneider and the team, thanks to Ft. Lauderdale-based Turnburry Aviation and its offer to fly doctors and nurses free to Haiti, were aboard an executive jet bound for Port-au-Prince. They arrived at the airport at midnight, and after a three-minute drive to the other end of the runway, found themselves in a United Nations compound in one of two large supply tents quickly converted to treat hundreds of patients injured in the earthquake. Schneider and the team looked over a sea of cots filled with severely injured patients being tended to by exhausted physicians and nurses in blue and green scrubs, some sound asleep curled up on the cement floor. They had been working for 48 hours straight and needed some rest. Could Schneider and her team take over right away? They did.

Half the team took one tent, the other half the other tent. They were pediatricians but right away they began taking care of adults, too. But quickly Schneider realized their value as pediatricians needed to be optimized in this emergent situation, citing a couple of cases she came across in which children were receiving inappropriate doses of medications by adult physicians. So she and the adult providers agreed all patients under 16 years of age would be worked up and treated by the pediatricians.

“There were tons of kids with lots of needs, and we knew what needed to be done,” Schneider said. “We’ll do their IV fluids, pain medications and antibiotics, and that’s what we did.”

But what the pediatric residents now faced they had not faced before – the daunting challenge of treating multiple traumas with little resources in the aftermath of a devastating natural disaster. As part of their training the residents had some experience in ERs treating traumas, but nothing like this. Even Schneider, an experienced emergency medicine physician and veteran of multiple medical missions to remote areas of developlng countries like Belize, Guyana  and Peru, as well as hurricane-ravaged Haiti 18 months earlier, had not seen so many crush injuries, fractures and open fractures in one place at one time. The smell of gangrene was in the air, Schneider said, and the crush injuries kept coming in.

“This elective had now gone from tropical medicine to disaster medicine,” Schneider said.  “We knew now we weren’t going to be killing worms – we’d be trying to save limbs.”

But not in the same way crush injuries are treated in the United States. There, physicians on day one cut through the skin and into the fascia to release the muscle to reduce swelling and allow blood to circulate in the limb to keep tissue alive. But Schneider and the team arrived in Haiti three days after the earthquake, far too late to perform a fasciotomy.

“Any damage that was done was already done,” Schneider said. “Besides, there was no sterile way to do it, there was no way to keep the wounds clean. We’d make more of a mess if we did fasciotomies.”

So, the goal shifted to detecting and preventing infections with antibiotics to prevent amputations. The limb would be dead, “insensate,” Schneider explained, but the child would be able to keep it and avoid the need for a prosthesis. But preventing infections meant monitoring temperatures with thermometers, something they didn’t have. So the team had to apply the traditional “grandmother’s touch” – the back of their hand on the patient’s forehead – to determine whether or not the child had a fever, a sign of infection. Moreover, Schneider and the residents had to closely monitor their young patients’ condition and need for more antibiotics to save their limbs.

“There were some limbs that obviously had to come off, that were already gangrenous. It smelled like death [in the tents],” Schneider said. “There were others, if we could stay on top of the antibiotics and the infections, that wouldn’t need to be amputated. That was pretty much the battle we were fighting from day three to day ten.”

But with a limited number of physicians and one nurse for every 75 patients in the tents, the pediatricians also took on multiple other roles: Washing out wounds in preparation for amputation by orthopedic surgeons, doing dressing changes for the patients, and helping them with toileting and personal hygiene.

“The residents are now mixing up the antibiotics and giving it, starting the IVs, hanging the IV fluids, changing the dressings, changing the children when they pee in the cot. They did everything,” Schneider said. “So the learning curve, even outside the skill of a normal pediatrician, was huge.”

So was the amount of sleeplessness. From the moment she arrived, Schneider was up for 38 hours, napped for an hour and a half, then up for another 30 hours before getting three hours of sleep. The residents were following a similar schedule. How were they able to function?

“From the time I was on the phone talking about Port-au-Prince, the adrenaline just started,” Schneider said. “A couple of residents said, I’ve been up for 30 hours but I’m not tired yet. We were just living on adrenaline, and there was so much to do and so much need. Every once in a while it would be ‘Oh my God, I can’t walk anymore, and I’d better go lie down.’ So you’d sleep for a few hours and something would wake you up and within 5 minutes you’d be back at work.”

Being members of a team helped, too.

“We knew each other, knew we could trust each other, knew what to do,” Schneider said. “We were an amazing pediatric team there.”

There was an emotional toll, too. The residents and Schneider all expressed sadness about the extent of injury and death they witnessed, and guilt about leaving for home. There were some “what ifs,” too, ruminating inside the physicians’ heads, like discovering the house you were supposed to stay in was destroyed by the earthquake 24 hour earlier.

“One day later we would have been in that house and nobody walked out of it. The five people that were there are dead,” Schneider said. “That really hasn’t sunk in yet, but I keep telling people maybe someday I’ll feel afraid that it was that close. I figure there’s still some work for me to do if I’m still here.”